Online Form

Surgical Release Form

Fill out the surgical release form accurately to ensure a smooth process for the pet’s procedure and to help us provide the best possible care.

Get Started

A happy white dog standing on its hind legs

Surgical Release Form

Please choose to fill out the surgical release form online for quick processing, or download the form using the button below if you prefer to complete it offline at your convenience.

Download Form

Owner’s Name *

First

Last

Phone Number *

Owner's Email *

Patient’s Name *

Procedure Date *

Referring Hospital *

Attending Veterinarian *

Surgical Procedure(s) to be Performed: *

Please Check If Applicable:

Left Leg
Right Leg

Consent and Authorization: I, the undersigned owner or agent of the owner, hereby consent to and authorize Dr. W. Wesley Kimberlin to perform the surgical procedure(s) listed above. I have discussed the listed surgical procedure(s) and importance of pre-surgical diagnostics (bloodwork, radiographs, etc) with the referring veterinarian. Your referring veterinarian and referring hospital will be performing the administration of anesthesia and monitoring, as deemed necessary. I understand that during the procedure, unforeseen conditions may arise that necessitate an extension or variance in the procedure(s) or additional treatments. I authorize Dr. Kimberlin and/or the referring veterinarian, along with their assistants, to perform any additional or different procedures that are necessary or advisable in their reasonable discretion for my pet’s health and well-being. *

Yes, I agree
No, I do not agree

Acknowledgment of Risks and Complications: I understand that all procedures and anesthetic protocols carry inherent risks, including but not limited to infection, hemorrhage, swelling, bruising, implant failure, allergic reactions, or even death. I understand that complications may require additional diagnostics and surgery at additional cost. I have discussed these risks with the referring veterinarian and/or Dr. Kimberlin and understand the potential complications that may arise. I accept these risks and consent to proceed with the surgery. *

Yes, I agree
No, I do not agree

Post-Operative Care: I understand the importance of post-operative care and will follow the instructions provided by the veterinary staff for the care of my pet after surgery. I agree to return for follow-up visits as directed and to contact the referring veterinary hospital immediately if any post-operative complications arise. I understand that failure to follow post-operative care instructions and/or failing to attend follow-up visits can result in the likelihood of the risks set forth above increasing in probability. *

Yes, I agree
No, I do not agree

failing monitoring, are

Authorization and Release: By signing below, I acknowledge that I have read and fully understand this consent form. I have had the opportunity to ask questions and have received satisfactory answers. I voluntarily give my consent and authorization for the above-named procedure(s) to be performed by Dr. Kimberlin and the referring veterinary hospital staff. *

Yes, I agree
No, I do not agree

Owner/Agent Signature: *

Clear Signature

Date *

Witness Signature *

Clear Signature

Date *