Online Form

Surgical Release Form

Complete your surgical release form online from any device at any time before your visit.

Surgical Release Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pets before your visit.

PLEASE BE SURE TO FAST YOUR PET THE DAY BEFORE SURGERY. NO FOOD AFTER 8PM AND NO WATER AFTER MIDNIGHT. DROP OFF TIME IS BETWEEN 8 AM AND 8:30 AM THE DAY OF SURGERY. IF YOU HAVE QUESTIONS REGARDING MEDICATIONS PLEASE CALL THE OFFICE.

I, being solely responsible for the above-named animal, have the sole, exclusive, and unconditional authority to grant Royersford Veterinary Hospital, Inc (RVH), its' veterinarians, and employees my consent to receive, prescribe for, treat and/or operate upon my pet. I understand the surgery/treatments contemplated is (Please specify any lumps or masses to be removed- request shaving to mark locations):

I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss my concerns about those risks with my attending veterinarian before the procedure is performed. Should some unexpected, life-threatening emergency care be required, and my attending veterinarian is unable to reach me, RVH has my permission to provide such treatments and I agree to pay for such care. I also understand that conditions not known may make it advisable that other surgery or treatments be done and I authorize such other surgery or treatment when and if they are deemed advisable.

I acknowledge that no assurance or guarantee has been made of the results of surgery or treatment and that risks and probabilities or complications exist in any surgical or medical treatment. I also understand that RVH is not staffed 24 hours a day; as such, hospitalized patients will not be supervised "around the clock."

I consent to the administration of such anesthesia as may be deemed proper by the doctor.

I understand that if an animal is not current on Rabies, Distemper virus, or parvovirus, vaccinations may be given and added to the cost of the above-described procedures. I understand that if parasites are found on or in my pet, treatment will be given and added to the cost of the above-prescribed procedures.

In the event my pet is hospitalized for more than 48 hours and my attending doctor is unable to reach me, I understand that it is my responsibility to call the hospital at least every 48 hours to inquire as to the medical status of my pet and the fees incurred for the services up to that day. If the pet is not called for in 3 days and all attempts to reach the client fail and no written notification of an alternate date of pick up of the pet is received from the client, the pet will be considered abandoned and may be disposed of as the doctor sees fit. It is understood that you so doing does not relieve me from paying all costs of your services and use of your hospital including the cost of boarding.

RVH will use all reasonable precautions against injury, escape, or demise of the animal, but you will not be held liable or responsible in any manner whatever, or any circumstances on account of the care, treatment, or safekeeping of the animal described above or otherwise in connection therewith as it is thoroughly understood that I assume all risks.

I understand the following are surgical options and have been advised of the benefits and risks associated with my decisions:

CPR/DNR

It is the nature of medicine that situations which cannot be predicted and which require emergency treatment may arise. In those situations, treatment often must be initiated immediately and without the veterinarian having time to confer with the owner. Because of this, we are asking you to state your wishes with regard to CPR and other emergency life saving procedures before leaving your animal. Please select only one of the options below:

If no selection is made, it will be assumed that you selected the option of CPR