Surgery Release Form

Surgery & Anesthesia Release

Northeast Animal Hospital | Tallahassee, FL

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Surgery/Anesthesia/Sedation Release (2026)

Northeast Animal Hospital | Tallahassee, FL

General Information

Date

Patient Name

Procedure(s)

Best Phone Number

Alt Emergency Number

Pet History Questionnaire

1. Are vaccines current?

2. Known Allergies/Reactions?

3. Current Medications?

4. Any food/water this morning?

5. On Heartworm Preventative?

Anesthesia & Recommended Safety Measures

Your pet is being admitted for a procedure that will require the use of anesthesia today. Our staff will use the safest anesthesia available and your pet will be constantly monitored throughout the procedure. However, regardless of an animal’s age or apparent health status, all anesthetic procedures do carry an element of risk. Before anesthesia, a simple blood test is performed which allows us to check the function of internal organs. Knowing how well these organs are working is vital to the safety of your pet. Your pet will be maintained on I.V. fluids throughout the procedure. The additional measures listed below are recommended for optimal safety and recovery, but are not required: (please initial on the line)

PLEASE INITIAL:

Cerenia Injection (Anti-Nausea)

The Cerenia injection is used to prevent post-operative vomiting for 24 hours; also has some pain reducing effects. $33.95 (for under 40 lbs; cost increases based on weight above 40 lbs)

I have read the above and APPROVE the administration of Cerenia during my pets surgery to prevent vomiting and reduce pain.

THERAPEUTIC LASER

Our Therapeutic Laser is used to reduce inflammation and bring healing factors to the treated area. This is especially beneficial in surgery because it accelerates healing, reduces post-operative pain, and can reduce the chance of healing complications. The cost for surgical laser therapy is $30

I have read the above and APPROVE the use of laser therapy during my pet’s surgery to decrease pain and speed post-op recovery ($30)

Add-On Dental Cleaning*

If your pet is here for a routine dental cleaning, please refer to the estimate(s) provided as below may not apply. Any pet over the age of 2 will already have some degree of dental disease. Dental disease can lead to permanent damage of the teeth and jaw bones, as well as contributing to kidney and heart disease. We recommend your pet have a dental cleaning while under anesthesia – this includes professional removal of all plaque and tartar, polishing the enamel and applying a sealant. A routine dental cleaning typically costs $500-550 (a large part of that is the anesthesia cost), while an add-on dental cleaning averages about $200. It is more cost-effective to have a dental cleaning done while your pet is already under anesthesia for other procedures.

YES, I have read the above and ACCEPT an add-on dental cleaning be performed (approx $200) NO, I have read the above and DECLINE an add-on dental cleaning at this time

Other Services (Check all that apply)

Regular Nail Trim $14

Nail Trim Back (Show Cut) $21.80

Anal Gland Expression $20.00

Pluck Ear Hair $15.00

Microchip $42.90

A heartworm test will be required if we do not have a current test result on file (within 12 months) OR if your pet has not been receiving monthly oral heartworm preventative or is not current on the 12-month ProHeart injection.

Legal Release & Authorization

I understand that there are risks associated with anesthesia and the procedures set forth above. I have read and understood the information above or have had it explained to my satisfaction. I understand that no guarantee or assurance has been made to me as to the results that may be obtained. I agree to hold Northeast Animal Hospital, its servants and agents from any loss or liability in connection with the above procedure(s). In the event complications arise and I cannot be immediately contacted at the provided phone number(s), the surgeon is directed to make the decision he/she deems best for my pet.

Signature (Typed Full Name)

Surgery Release Form

Surgery & Anesthesia Release

Surgery/Anesthesia/Sedation Release (2026)

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Address

1407 Timberlane Rd, Tallahassee, FL 32312

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