Canine/Feline Surgical Release Form

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Client Name*
First Last
Client Email*
Patient Name*
Patient Age*
Date*
MM slash DD slash YYYY
Pre-Anesthetic Blood Work (Dogs & Cats)
Your pet is being admitted for a procedure that will involve anesthesia. Although we take every caution and use up to date monitoring devices, there are always potential risks when performing surgery on an animal. To further insure the safety of your pet we strongly recommend that a pre-surgical blood screen be run on your pet 0-7 years of age. A geriatric blood screen is REQUIRED for all patients 8 years and older prior to having anesthesia. Our pre-anesthetic screens are run to maximize patient safety and alert our doctors to the presence of dehydration, diabetes, anemia, kidney disease, or liver disease. Any of these conditions could complicate a surgical procedure. The fee for the recommended pre-surgical blood screen is $92.00. The fee for the REQUIRED geriatric blood screen is also $92.00.
Please Check Yes or No*
- YES – Please run the pre-anesthetic blood screen recommended prior to anesthesia. If any abnormalities are found, please contact me at the number provided.
- NO – I have elected not to have the recommended blood screen and authorize you to proceed with anesthesia.
Feline Leukemia and Feline Immunodeficiency Virus (Cats Only)
Feline Leukemia (FELV) and feline immunodeficiency virus (FIV) are the most common and destructive of all cat viruses. FELV is spread primarily by saliva but may also be spread by blood, urine, and feces. Kittens may become infected while still in the womb. The best means of preventing FELV infection is by vaccinating your cat before it is exposed to the virus. A cat or kitten that is exposed to FELV and then vaccinated is NOT PROTECTED from this deadly virus and is contagious to other cats. Stafford Veterinary Center strongly recommends a simple blood test to determine whether your pet has been infected, and if negative we recommend vaccinations. The fee for this test is $72.00 and the fee for the FELV vaccination is $40.00. This is an initial vaccine and will be boostered four weeks later and will become an annual vaccine.
Please Check Yes or No
- Yes – Please test my cat for FELV and FIV and if negative please vacccinate for FELV. If the test comes back positive for either FELV or FIV, I can be reached at the number provided to discuss.
- No – I have elected to refuse the recommended FELV and FIV screening.
Propofol (Dogs Only)
Propofol is a state of the art anesthetic that is used for rapid and smooth recovery. This type of anesthesia is highly recommended for any dogs that may have health concerns such as compromised liver functions, kidney disease, diabetes, anemia, or Lyme disease. It is also highly recommended for older dogs as well as sensitive breeds. The patient recovery period is shorter since Propofol leaves their system much sooner than the traditional anesthesia. Additional costs range from $99.00-$110.00 depending on weight. Our traditional anesthesia is very safe and appropriate in most routine surgical situations.
Please Check Yes or No
- Yes – I elect to use Propofol for my dog. I understand there will be an additional cost.
- No – I do not wish to have my dog receive Propofol.
Canine/Feline Spay Procedures
For cat and dog spay procedures: In the event your animal is determined to be pregnant do you wish the doctor to continue with the spay surgery (which will terminate the pregnancy)?
- Yes – continue with the surgery
- No – do not continue with the surgery
Owner's Name (your name here represents your digital signature)*
First Last
Date*
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Client Resources

Canine/Feline Surgical Release Form

Pre-Anesthetic Blood Work (Dogs & Cats)

Feline Leukemia and Feline Immunodeficiency Virus (Cats Only)

Propofol (Dogs Only)

Canine/Feline Spay Procedures

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ANIMAL HOSPITAL AFFILIATIONS