Surgery Admission Form -

Name

First Last

Email*

Phone

About Your Pet

Pet's Name*

Procedure(s)

Age

Species*

Sex*

Male / Unaltered
Male / Neutered
Female / Unaltered
Female / Spayed

The last time my pet ate ANYTHING AT ALL was:

Has your pet had aspirin or any other medicine or supplements within the past 7 days?

Yes
No

Which medication/supplements(s):

What dose & strength?:

When?:

How many tablets, capsules, or ccs were administered?

Does your pet find it particularly distressing when away from home as when at a boarding facility?

Yes
No
Not sure

Is your pet crate trained or used to being in a crate?

Yes
No

Has your pet had a history of aggressive licking or chewing surgical incisions or wounds?

Yes
No
Not sure

Do you anticipate that there will be any problems keeping your pet in a clean, dry area during the entire recovery (typically 14 days)?

Yes
No

Do you anticipate that there will be any problems keeping your pet reasonably quiet during recovery?

Yes
No

Do you have any questions for the surgeon this morning?

Yes
No

Enter your questions below:

Has your phone number or address changed since you last visited our practice?

Yes
No

New Phone Number:

Has your pet ever had a past anesthetic event that you thought went poorly?

Yes
No

Please explain:

Consent*

I have read and agree to the statements below.

I certify that I am the owner, or an authorized agent for the owner, of the above animal. I hereby consent to and authorize the doctors and staff at this veterinary practice to admit this pet, perform the above-described procedures, and administer medications, anesthesia, surgical procedures, tests, and or treatments that the doctors deem necessary for its health, safety, and well being while under their care and supervision. I have been advised of the nature of the procedures and the potential risks and benefits. I understand that veterinary medicine is an inexact science and that no guarantee of successful treatment can be made.

I understand that antibiotics (oral or injectable), pain medication (oral or injectable), and anti-inflammatory medication may be prescribed for my pet per the veterinarian's discretion. I also understand my pet must be free from both internal and external parasites while in the clinic. If parasites are found, my pet will be treated, and this will be at additional cost to the fees provided on the estimate.

I acknowledge that I am responsible for payment in full for the above procedures and treatments at the time my pet is
discharged.

In case of emergency, I can be reached at:*

YOU MUST PROVIDE A NUMBER WHERE YOU CAN BE REACHED IMMEDIATELY IN THE UNLIKELY EVENT AN EMERGENCY WITH YOUR PET SHOULD ARISE.

Pre-Anesthetic Lab Work

If your pet is undergoing an anesthetic procedure, rest assured that advances in anesthesia, anesthetic monitoring, and surgery have made procedures safer with a low rate of complications. Nevertheless, some obscure conditions can be detected only by diagnostic testing and will not be obvious on physical exam. Because of this, we recommend various pre-anesthetic screening tests. This testing is required for pets 6 years of age and older.

Complete blood count, chemistry panel and electrolytes: $142.95

I have been advised of this additional cost and consent to having these tests performed.

Yes
No

As an option to detect abnormal electrical activity in the heart, an ECG can be performed: $107.98

I consent to have the optional ECG screen test performed on my pet.

Yes
No

Additional Services

There are many additional services that your pet may benefit from while under anesthesia. You may consent to any of these procedures below.

Hip Dysplasia Screening

Large breed dogs often suffer from a painful and disabling condition called hip dysplasia. Once diagnosed, medications, physical activities or surgeries can be prescribed or performed to improve your pet’s comfort level. We are able to screen for this condition while your pet is under anesthesia. If you consent, a pelvic examination, manipulation and radiographs will be performed on your pet.

I consent to have this procedure performed.

General Radiograph: $171.71
OFA: $336.96
Neither / No

Dental Extractions

Small breed pets often suffer from retained deciduate (baby) teeth after their adult teeth grow in. This condition creates overcrowding of teeth, retention of food or other debris between the teeth, and tarter buildup. This, in turn, leads to bad breath and damage to gums and adult teeth. We strongly recommend that these deciduate teeth be extracted while your pet is under anesthesia to avoid future complications. The cost for this procedure varies based the number of teeth extracted but usually ranges from $37.54 to $57.50 per extraction.

If my pet has this condition I consent to have this procedure performed.

Yes
No

Microchipping: $40.00

Microchipping pets involves inserting a tiny rice-like microchip under your pet’s skin. This chip then holds your pet’s identity for life. If your pet is ever lost and a local shelter or veterinary practice finds it, the law requires that all pets be scanned for a microchip before they are adopted out or euthanized.

I agree to have a microchip inserted.

Yes
No

Consent*

I agree that the information submitted in this form is correct to the best of my knowledge, and by entering my name below and submitting this form, I consent to the services and procedures indicated above.

Signature*

First Last