Owner's Name *

First

Last

Patient's Name *

Address *

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Address Line 2

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Age *

Sex *

Male
Neutered Male
Female
Spayed Female

Species *

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Pet History

Surgery Check-In

Procedure to be performed *

Did your pet eat this morning? *

Yes
No

Does your pet have drug / vaccine reaction? *

Yes
No

If yes, please list

Does your pet have pet insurance? *

Yes
No

If yes, please list

Has your pet had any history of seizures and/or any previous anesthetic problems *

Yes
No

Is your pet currently on any medications?

Is your pet in heat or pregnant? *

Yes
No

Cryptorchid? *

Yes
No

Does your pet have retained deciduous teeth? *

Yes
No

Is your pet on Heartworm preventative? *

Yes
No

If yes, what prevention is your pet on?

Date last given

Owner authorization and release

Authorize the recommended E-COLLAR to prevent your pet from licking at incision site at the cost of $17.50 *

I do
I do not

Authorize Pet Link Microchip identification implant $39.99 *

I do
I do not

Authorize Anal Glands at the cost of $17.00 *

I do
I do not

Authorize Ear Pluck/Ear Cleaning at the cost of $16.00/$18.00 *

I do
I do not

All patients must have current PRE-ANESTHETIC blood screening prior to anesthesia per Doctor recommendations.

If your pet comes in with FLEAS we will administer treatment at the cost of $10.00

The nature and purpose of these procedures and treatments and available alternative treatments have been explained to me. I understand that anesthesia and surgery always involve some risk to my pet (such as unknown internal physical abnormalities, medication allergies, surgical complications, internal bleeding, shock, incision dehiscence, and post-surgical infections): and agree to hold you harmless, in the absence of negligence, in connection with these procedures. I understand that I will be held financially responsible for any veterinary medical care necessitated by these complications. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. In the event that complications arise and I cannot be immediately contacted at the below listed phone number, you are directed to make the decision you deem best for my pet. I consent to the administration of sedatives, analgesics, and anesthetic agents as deemed appropriate by the veterinarian in charge. I agree to pay for services rendered.

The nature and purpose of these procedures and treatments and available alternative treatments have been explained to me. I understand that anesthesia and surgery always involve some risk to my pet (such as unknown internal physical abnormalities, medication allergies, surgical complications, internal bleeding, shock, incision dehiscence, and post-surgical infections): and agree to hold you harmless, in the absence of negligence, in connection with these procedures. I understand that I will be held financially responsible for any veterinary medical care necessitated by these complications. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. In the event that complications arise and I cannot be immediately contacted at the below listed phone number, you are directed to make the decision you deem best for my pet. I consent to the administration of sedatives, analgesics, and anesthetic agents as deemed appropriate by the veterinarian in charge. I agree to pay for services rendered. *

I have read the foregoing, understand what it says, and agree.

Signature *

Clear Signature

Date *

Who will be picking animal up?

Phone Number *

Would you prefer updates via phone call or text message? *

CALL
TEXT

Surgery Check-In Form

Surgery Check-In Form

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