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Contact
Surgical Admission Form
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" indicates required fields
Step
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Phone
This field is for validation purposes and should be left unchanged.
Please provide at least 24 hours prior to appointment
Dogs/Cats: Please withhold food and water 12 hours before your pet's admission appointment.
For Exotics/Birds please call the hospital for withholding food and water instructions.
Name
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First
Last
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Pet's Name
*
Email Address
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Have you been exposed to anyone knowingly with COVID-19 illness in the last 14 days?
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Yes
No
Are you or any family member experiencing any signs of COVID-19 illness like fever, cough, body-aches, or loss of taste or smell?
*
Yes
No
Surgical Procedure to be performed
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Note: Masks are now optional to wear on the day of your appointment.
Is your pet on medication?
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Yes
No
I, the undersigned owner or agent of the owner of the pet identified above, certify that
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I am over eighteen years of age eighteen years of age or older and authorize the veterinarian to perform the above procedure(s).
I am not over eighteen years of age eighteen years of age or older and authorize the veterinarian to perform the above procedure(s).
I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:
The reasonable medical and/or surgical treatment options for my pet
Sufficient details of the procedures to understand what will be performed
How fully my pet will recover and how long it will take
The most common and serious complications
The length and type of follow-up care and home restraint required
The estimate of the fees for all services
Any necessary payment arrangements
While I accept that all procedures will be performed to the best of the abilities of the veterinarian and the staff at this hospital, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff
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does have (CPR) my permission to provide such treatment and I agree to pay for such services.
does not have (DNR) my permission to provide such treatment and I agree to pay for such services.
I understand that a treatment plan of the fees for the above procedures will be emailed to me and that I am encouraged to discuss all fees related to such care before services are rendered. I agree to pay and assume financial responsibility for the balance of services rendered, and agree to provide payment of cash or credit card on the day of service. I understand full payment is required at the time of service.
In the event my pet is hospitalized beyond the day admission at this facility, I understand that veterinary care during nighttime hours and/or weekends is not provided at this facility. If my pet needs overnight hospitalization and I do not want to have my pet hospitalized when this facility is closed and no veterinary staff are present to supervise in the facility, I elect to
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pick up my pet and provide such care in my home, in which case I accept all risks of adverse effects
have him/her transferred to a local emergency clinic where overnight veterinary supervision is available at my expense
I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made. I have read and understand the nature of the above procedures and give my consent to proceed.
Date
*
Signature
*
First
Last
I will take my pet’s belongings home with me (leashes, sweater, toy etc.):
*
Yes
No
We prefer that you take your pet’s belongings (collar, leash, etc..) home with you.
If you need to leave any belongings here, please list below (include color of items):
If you are leaving your pet’s crate at the hospital, please list color and label your carrier with your pet's name.
If it is recommended for your pet to go home with oral medications would you prefer (sometimes liquid is not available for some medications)
liquid medications
pill/capsule medications
In addition to this estimate I would like the following procedures to be performed on my pet, while he/she is under anesthesia and or sedation today and I agree to be responsible for the additional cost of these items as listed below
$0 Nail trim
$60 Nail trim and Dremel (smooths sharp edges)
$67.50 Anal sac expression
$98.50 Microchipping
$57.00 Ear cleaning
$172.00 Pelvic radiograph (hip evaluation)
$0 Permission to board multiple pets from same family in one kennel
$100 Dr. discretion – Miscellaneous (if you cannot be reached by phone)
Doctor discretion – treatment items recommended if you cannot be reached by phone. Please leave dollar amount you authorize:
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