Clients Name *

Appointment Date

Address *

Address Line 1

City

State

Zip Code

Phone *

Email *

Email Reminders: *

Yes
No

Patient Name *

Daytime Name/Phone Number

(if different than above)

Procedures to be performed today *

Medications

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?

What type? *

How often? *

What time did your pet receive medication today?

Is your pet treated for fleas? (type and last date given) *

If your pet is not microchipped, would you like us to implant one today for $54? *

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.

We offer post-op sedation to help keep pets quiet and comfortable at home following a surgery procedure. This is dispensed medication to be administered by you. 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 *

Clear Signature

(initial)

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

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/Credit Card
Cash
Care Credit Account

Signature *

Clear Signature

Date *

Surgery Admission and Consent Form

Contact

Location

Open Hours