Mass Removal Form Patient:*Release Date Client NameType Cat Dog Side Left Right RegionNumber of Masses RegionNumber of Masses RegionNumber of Masses RegionNumber of Masses I acknowledge that the area(s) marked above are the only location(s) discussed for removal, and authorize the removal of additional masses if found while the patient is under anesthesia. I realize that there maybe additional charges for such removal(s).* I Agree I acknowledge that the area(s) marked above are the only location(s) discussed for removal and DO NOT authorize the removal of additional masses found while patient is under anesthesia.* I Agree Signature*
