Surgery Release Form

  • MM slash DD slash YYYY
  • 434-971-9800

    Autumn Trails Veterinary Center

    Jennifer Cardoza, DVM

    Valerie Babcock, DVM

  • I, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above, that I do hereby give Autumn Trails Veterinary Center, Jennifer Cardoza, DVM, her agents, servants and/or representatives full and complete authority to perform the surgical procedure described as:

  • and to perform any other procedure that, at his discretion, may be useful to promote the health of the above described pet, and I do hereby and by the presents forever release the said Doctor, his agents, servants or representatives from any and all liability arising form said surgery on said animal.

    I, the undersigned, do hereby certify that I have received an estimate for the procedure described above and understand that full payment is due at the time of service.

    If the doctor recommends pre-anesthetic bloodwork, the price will be included in the estimate. It will be up to the discretion of the doctor to have the bloodwork be optional prior to the procedure. Given if the bloodwork is optional, please initial below if you would live to have it performed.