Surgical Release Form

Save time during your next appointment! Complete your Surgical Released required forms online from any device at any time before your visit.

Ready to start your Surgical Release Form

Owner's Name *

First

Last

Email *

Phone I can be reached at today. *

Patient's Name *

Referring Hospital *

Referring Veterinarian *

Procedure Date

IF YOU ARE UNSURE WHICH PROCEDURE YOUR PET IS HAVING WITH HILL COUNTRY VETERINARY SURGICAL SPECIALTY, PLEASE CONTACT OUR OFFICE AT (830) 549-1698 OR EMAIL US AT info@hcvss.com TO ENSURE THE CORRECT PROCEDURE IS LISTED AND DETAILS ABOUT THE SURGERY ARE AVAILABLE. *

I have read and understand.

Procedure

Achilles Tendon Repair
Arthrodesis
Brachycephalic Airway Syndrome
Corkscrew Tail Amputation / Caudectomy
Exploratory Laparotomy Surgery
Extracapsular Cranial Cruciate Repair
Fracture Repair
Jaw Fracture Repair
Neutral (Modified) Cranial Closing Wedge Ostectomy (NCCWO)
Patella Luxation
Perineal Urethrostomy - Cat
Sacroiliac (SI) Luxation
Subtotal Colectomy
TPLO or CBLO Cruciate Repair
Ventral Bulla Osteotomy
Anal Sacculectomy, Marsupialization
Arytenoid Lateralization
Cherry Eye
Coxofemoral Luxation Toggle Repair
Digit Amputation
External Abdominal Hernia
Extracapsular Repair/MPL
General Surgery
Joint Luxation
Mass or Tumor Removal
OCD Removal
Penile Amputation / Scrotal Urethrostomy
Physeal Injury, Forelimb Angular Limb Deformity, Ulnar Ostectomy
Salivary Mucocele
Superficial Digital Flexor Tendon Luxation Repair
TPLO & Patella Luxation Repair
Vulvoplasty/Episiotomy
Anal Tumor
Bone Biopsy
Cleft Palate Repair
Cystotomy for Urolith Removal
Esophagostomy Tube Placement
External Fixator Fracture Repair
FHNO
IM Pin, Nylon Suture, or Osteophyte Removal
Leg Amputation
Nephrectomy
Orthopedic Plate, IM Pin, or Nylon Suture Removal
Perineal Hernia Repair
Prophylactic Gastropexy
Splenectomy
Synovial Aspirate
Total Ear Canal Ablation (TECA) and Lateral Bulla Osteotomy

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 (Drs. Dosal, Franklin, Harper, Kiefer, and Souza) of Hill Country Veterinary Surgical Services, to perform surgery and/or diagnostic procedures on my pet. I am also aware that Drs. Harper and Souza are board certified in large animal surgery only but have retrained in small animal surgery as well, therefore, offers their services to small animal clients and their animals. I have also been made aware that Dr. Franklin is small animal surgery residency trained but has not become board-certified. At this time, Dr. Franklin’s title is Practice Limited to Surgery. Dr. Dosal is a general practitioner who spent the last three years under Dr. Harper crafting his trade in small animal surgery as well as completing the Improve International Certificate Program in Small Animal Surgery. I understand that there are other board-certified surgeons in small animal available in the area. Dr. Kiefer is board certified in small 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 TSVS is closed on weekends) of the scheduled surgery date. *

A cancellation fee of $500 will be charged if the procedure is cancelled or rescheduled within 24 hours of the scheduled surgery date. *

I have read and acknowledge the cancellation fee.

Hill Country Veterinary Surgical Specialty (HCVSS) and TSVS Rehab and Conditioning 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. This may, also, include "Graduation" photos from TSVS Rehabilitation and Conditioning programs offered with our certified Rehab technician, Kim Barrier. We may mention your pet by name, but never the owner’s name. TSVS 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

We help your pet get back to feeling its best.

Hill Country Veterinary Surgical Specialty is the first and only local veterinary surgery center in the Boerne/Hill Country area. We partner with your family vet to provide your pet with surgical expertise in orthopedic and soft tissue surgery. All we do is surgery!

We proudly serve pets from Boerne, San Antonio, Fredericksburg, New Braunfels, San Marcos, Bandera, and more!

Need a hotel? We have so many clients from out of town and out of state that we created a list of nearby pet-friendly hotels and dining, lodging, etc.
Simply ask for it, so you don’t have to reinvent the wheel.

Have questions?

Click the button below to fill out our contact form! We’ll be here to answer any and all of your questions.

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Location

826 Johns Rd.
Boerne, TX 78006

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Contact Info

P: 830-549-1698
E: info@hcvss.com – for clients
E: rads@hcvss.com – for referring veterinarians

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Hours

By appointment only.

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