Appointment Date *

Client Name *

Client Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email Address *

Email Reminders *

Yes
No

Patient Name *

Species *

Dog
Cat
Other

If other, please specify *

Breed *

Color *

Is your pet *

Spayed
Neutered
Intact

Age *

Weight *

Microchip# *

Daytime Name/Phone Number: (if different than above)

Procedure(s) to be performed today *

Medication(s)

Known adverse reactions to any medications

For our surgery patients under 8 years old, pre-anesthetic blood work is not required but we recommend it to identify "at risk" patients. The risks of anesthesia increase with age, therefore, if your pet is 8 years or older, we do not recommend surgery without pre-anesthetic screening *

Yes, I want the blood work for an additional $131.
No, I decline this blood work and am aware of the risks.

Did your pet eat today? *

Yes
No

Have you noticed any vomiting, diarrhea, and/or coughing during the past 7 days? *

Yes
No

Does your pet have a history of allergic reactions or difficulty following anesthesia? *

Yes
No

Is your pet on any additional medication?

Yes
No

What type?

How often?

What time did your pet receive medication today?

Is your pet treated for fleas?

Yes
No

Type and last date given

If your pet is not microchipped, would you like us to implant one today for $54.00? *

Yes
No

If the doctor feels it is necessary due to your pet's age/health condition, your pet may be put on IV/SQ fluids. *

I have read and understand.

We offer post-op sedation to help keep pets calm and comfortable at home following a procedure. This is dispensed medicaton to be administered by you. Additional charges will apply. Would you like home sedation for your pet? *

Yes
No

If your pet is not current on recommended and required vaccinations, I understand vaccinations will be administered today at the doctor's discretion *

Are there any questions or concerns you have for the veterinarian?

NOTE: We are committed to the practice of high-quality medicine; therefore, your pet may be prescribed and you may be charged for additional pain relief medications and/or antibiotics upon discharge.

Statement of Medical and Financial Responsibility:

I hereby give my consent and accept financial responsibility for the above listed procedure(s) to be performed. Even though pets are given a pre-procedure exam, I understand that there are risks involved in the administration of general anesthesia and in performing all surgeries; therefore, I give permission for the performance of any additional treatments necessary for the welfare of my pet. *

I understand that payment is due in full upon my pet’s discharge.

My method of payment will be: *

Check
Debit or Credit Card
Cash
Care Credit Account

Signature *

Clear Signature

Date *

Admission & Consent Form for Surgery

Admission & Consent Form for Surgery

Statement of Medical and Financial Responsibility:

Contact

Location

Open Hours