615-384-5393 rcacvet@gmail.com

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Please Note: We will be closing early at 12 PM on Tuesday, December 24th and will be fully closed on Wednesday, December 25th in observance of Christmas!

Surgical Release Form

GET STARTED

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Surgical Release Form

Please complete the form before your visit. We will get in touch with you if we have any questions.

Client Name *

First

Last

Email *

Patient Name *

Phone number at which owner can be reached today or tomorrow: *

Additional number

Before Procedure:

Would you like to be contacted before your pet goes in for the procedure? *

Yes
No

Would you like to be contacted by text or phone call before the procedure? *

Text
Call
Either

If text, at what number would you like to be texted?

After procedure:

Would you like us to text you after the procedure, or would you prefer a call? *

Text
Call

Anesthetic and surgical procedure(s) to be performed: *

I, the undersigned owner or agent of the pet identified above, authorize the staff of Robertson County Animal Clinic to perform the above procedure(s). *

I have read and agree

Microchip: *There is an additional fee for this procedure* *

Yes
No
Already has one

Nail Trim: Would you like a complimentary nail trim for your pet? *

Yes
No

Have you given your pets any medications or supplements in the past week? *

Yes, pre-surgical pack
Yes, other medication(s) (please specify below)
No

Other medication(s), please specify and note last time given

When was the last time fed?

Any other concerns/allergies/procedures?

I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. *

I have read and agree

I am over 18 and understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life-sustaining procedures. *

I give my permission [yes]
I do not give my permission [no]

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow-up radiographs, re-check physical exams, and additional surgery due to postoperative complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above. *

I have read and agree

Signature *

Clear Signature

Date *

Website

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Location

800 5th Ave E
Springfield, TN 37172

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Hours

MON-FRI: 7:30 am – 5:30 pm (Appts. start at 8:00 am)
SAT: 7:30 am – 1 pm

Closed 12 pm – 1 pm for lunch

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Contact Us

P: 615-384-5393
E: rcacvet@gmail.com

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High-quality veterinary care for pets in Springfield, TN and beyond

We are dedicated to partnering with you in giving your pets the care they deserve. They are always there for you, and we know you want to do the same for them. That is why it is our goal to educate and empower you to do all you can to give them the longest and healthiest life possible. Utilizing advanced medical practices and technology, we strive to enhance your pet’s well-being and quality of life. We look forward to seeing you soon.

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Download our app to stay connected with your pet!

Download the free PetDesk app from your Google Play Store or App Store on your smartphone today! Here you can request appointments, receive reminders for your pets, and access your pet’s veterinary care history.

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