Surgery Anesthesia Release Form

Chateau Animal Hospital


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I, the undersigned, do hereby certify that I am owner (duly authorized agent for the owner) of the animal described above, that I give Chateau Animal Hospital, agents, and/or representatives full and complete authority to perform the surgical procedure described as:

and to perform any other procedure that,
at his/her discretion, may be useful to promote the health of the above-described pet, and I do hereby forever release the doctor, his agents, or representatives from any and all liability arising from said surgery as long as reasonable care and precautions are maintained. I hereby authorize the performance of professionally accepted general anesthetic procedures necessary for its treatment.
I understand that support personnel will be used as deemed necessary by the veterinarian.

I have been advised as to the nature of the procedures and the risks involved in performing general anesthesia to the above-described animal. I realize that results cannot be guaranteed.

Any specific medical history we need to know about?

Microchip Implantation $77.00


You may elect to have your pet microchipped while he/she is under anesthesia. Your pet’s information will be loaded into a national database for identification to help with recovery is he/she were to become lost.
E-Collar or Medical Pet Shirt


This will help prevent chewing at the incision site.
Post Operative Anti-Nausea $ 32


Cerenia is a post op anti-nausea injection to help relieve nausea that can be associated with anesthetic medications.
Would you like a nail trim $23


Would you like a nail trim with dremel $34


I have read and understand this authorization and consent. I further understand that I assume financial responsibility for all services rendered.


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