Surgical Release Form


  • Date Format: MM slash DD slash YYYY
  • Additional Services

    Please check any additional services you would like us to provide while your pet is under anesthesia.
  • Consent to Treatment

    I hereby authorize Riverside Animal Hospital to perform the surgery and any additional diagnostic and treatment procedures as deemed advisable for my pet. The nature of the surgery has been explained to me and no guarantee has been made as to the results or cure. I understand that there may be risks involved. If my pet should pass away or become ill during or after surgery, I will not hold Riverside Animal Hospital and the staff responsible or liable for gross negligence. If my animal has fleas or ticks I understand that they will be treated. I agree to pay in full for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. Any estimates or charges for the planned procedures are only approximations, and the final bill may be greater or less than these amounts. All services must be paid for at the time of release. Some procedures require a deposit be made before surgery. If I am unable to be reached in the event of an emergency any necessary lifesaving procedures will be done to save my pets life.
  • Signature

    When you arrive to drop off your pet(s), our receptionists will print this form and ask you to sign below.