Owner Name *

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Last

Owner Email *

Owner Phone *

Patient's Name *

Referring Hospital *

Referring Veterinarian *

Procedure Date

IF YOU ARE UNSURE WHICH PROCEDURE YOUR PET IS HAVING WITH BOWLING GREEN VETERINARY SURGICAL SPECIALTY. PLEASE CONTACT OUR OFFICE AT (364) 201-5641 OR EMAIL US AT info@bgvss.com TO ENSURE THE CORRECT PROCEDURE IS LISTED AND DETAILS ABOUT THE SURGERY ARE AVAILABLE. *

I have read and understand.

Procedure: *

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the below-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: (Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks). This surgical procedure has an increased risk of anesthetic complication due to the breed of the patients it is performed on. We do not anticipate any in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: 1. Infection (less than 3%) which may require additional testing and medication at an additional cost. 2. Blood clots that can lodge in major organs causing stroke or rarely death. 3. Nerve injury which can be temporary or permanent (very rare) 4. Arthritis in future months necessitating additional surgery at an additional cost. *

I have read and understand the risks.

I authorize the surgeons and/or associates (Dr. Nunley) of Bowling Green Veterinary Surgical Services, to perform surgery and/or diagnostic procedures on my pet. I am also aware that Dr. Nunley are board certified surgeons. Dr. Nunley is board certified in small and or large animal surgery. *

I have read and authorize.

A cancellation fee of $500 will be charged if the procedure is cancelled or rescheduled within 24 hours (not to include Saturday or Sunday as BGVSS is closed on weekends) of the scheduled surgery date. *

I have read and acknowledge the cancellation fee.

Bowling Green Veterinary Surgical Specialty (BGVSS) occasionally feature patients on its Facebook page, YouTube channel, other social media sites, and in publications (print or online). With your permission, we may share your pet's picture, video or story. We may mention your pet by name, but never the owner’s name. BGVSS would be grateful that you'll be helping other pets by educating pet owners, veterinary technicians, and veterinarians. *

I consent to using my pet on social media or website.
I do not consent to using my pet on social media or website.

I authorize and understand by verbal consent and written consent the above information. *

I authorize and consent.

Owner's Signature *

Clear Signature

Surgical Release Form

Surgical Release Form

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