Door County Veterinary Hospital

3915 Old HWY Rd.
Sturgeon Bay, WI 54235


Surgical & Anesthesia Release


Surgical & Anesthesia Release Form

Surgery Procedure(s) to be performed:

Our greatest concern is the well being of your pet, just like with humans there are inherent risks with surgery and anesthesia. To minimize these risks your pet will be examined before administering anesthesia.
We highly recommend preanesthetic blood screening to help insure your pet's recovery.
We check for dehydration, anemia, infection, diabetes, liver/kidney disease, and other conditions your pet may have acquired or have had since birth that have not yet surfaced.
Often these problems do not show up on routine physical exams. The kidney and liver in particular must be functioning at 100% to filter out the anesthesia so your pets can recover uneventfully.
The preanesthetic screen results will help the doctor determine the best anesthetic protocol for your pet.
Presurgical Work-Up
I would like Chem12/CBC (recommend far all pets)
I decline preanesthetic bloodwork for my pet
We recommend intravenous fluids during anesthesia to maintain hydration and blood pressure, which also aids in anesthetic recovery. The use of IV fluids can also assist in administration of IV drugs should an abnormality arise.
I would like to have IV fluids during anesthesia
I decline IV fluids during anesthesia
Is your pet currently on any medications?
Time pet ate last?

Has your pet had any seizures?

For female pet in for spay surgery: If she is found pregnant, what would you like us to do?

Text Area

Other Services Requested:
Rabies Vaccine
DHPP Vaccine
Bordetella Vaccine
Lyme Vaccine
FVRCP Vaccine
Feline Leukemia
Fecal Exam or Dewormer
Heartworm Test
IV Fluids
Anal Gland Expression
Ear Pluck/Clean
Home Again Microchip

I hereby consent that I am 18 yrs. or older and able to authorize the Door County Veterinary Hospital staff to anesthetize and perform the above listed surgical and medical procedures on my pet. I understand there are always risks when using anesthesia or performing surgery.
The Door County Veterinary Hospital staff agrees to use all reasonable precaution against injury, escape, or death of my pet. I have read the above and agree.
If my pet is hospitalized beyond the first day at this facility, I understand that veterinary care during night time hours is NOT provided. Continuous presence of personnel will NOT be provided during these hours.
If I desire that my pet have supervision when this facility is closed, I elect to: (required)
Pick up my pet and care for him/her at home and I accept the risks involved.
Have my pet transferred to a local emergency clinic where an on-call doctor and supervision is available at my expense.
Signature (Please type first and last name): (required)

Date: (required)

Contact Phone Number: (required)

Please provide a phone number you or an authorizing party can be reached at, on short notice. If there are questions or if unforeseen conditions arise we will act in the best interest of your pet based on the veterinarians professional judgement.
However we would always prefer to discuss matters with you at the contact phone number provided.

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