North Reading Veterinary Clinic

212 Main St.
North Reading, MA 01864


Surgery Release Form

Authorization to perform anesthesia, surgery, and/or other services.
I, the undersigned, do hereby authorize the N.R.V.C. to perform the service(s) listed.
The nature of the service listed above has been described to me and to my satisfaction. I realize that no guarantee or warranty can ethically or professionally be made regards the results or cure.
I assume full financial responsibility for all services rendered, and understand that payment is due upon the discharge of animal described below. I understand that there will be additional charges for dental extractions or other added procedures, the doctor will call to discuss these charges.
Animal's Name (required)

Animals' D.O.B.

Species (required)

Breed/Color (required)

Type Your Name Below for Signature (required)

Date (required) :
Phone (required)
Phone TypePhone Number (required)
Would you like us to microchip your pet while under anesthesia - $53.00


Check the types of medication you are able to give to your pet. (required)
Like you, our greatest concern is the well being of your pet. Before putting your animal under anesthesia, we will perform a full physical exam.
However, many conditions, including disorders of the liver, kidneys, or blood are not detected unless blood testing is performed. Such tests are especially important before any kind of surgery.
For these reasons, we highly recommended blood screening before such procedures. The additional cost of this important blood test is _________.
Our laboratory is fully equipped and staffed to perform these blood tests.
Results will be immediately available to examine before anesthesia/surgery.
Please check one (required)

YES, I WANT my pet to have pre-anesthesia blood screen.
NO, I DO NOT want my pet to have pre-anesthesia blood screen.

Type your name for signature below. (required)

Date (required) :

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