All Creatures Animal Clinic Patient Admission and Consent Form- General Surgery
Patient Information
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Pet's Name
Last Name
Breed
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Age/Date of Birth
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Best phone number to contact you
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Area Code
Phone Number
Alternate phone number
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Area Code
Phone Number
Date of Appointment
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Month
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Day
Year
Date
Procedure(s) to be performed
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Ex: Spay, Neuter, Dental, Extractions, Mass Removal, Wound Repair, Ear hematoma etc
I agree that my pet will not eat anything past midnight the night prior to the procedure.
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Yes
No
Current Diet
Has your pet been coughing, wheezing, or breathing hard?
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Yes
No
Has your pet been vomiting or having diarrhea?
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Yes
No
Do you want your pet microchipped? (additional charges apply)
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Yes
No
Does your pet have any allergies?
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Yes
No
If yes, please list:
Has your pet ever had an adverse reaction to medication?
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Yes
No
If yes, please explain:
Is your pet taking any medications?
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Yes
No
If yes, please list medications, dosage and time last given
I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize the above procedure to be performed by All Creatures Animal Clinic. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian. I have been advised as to the nature of this procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand there is always a risk associated with any anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. Procedure risks include serious bodily injury or death. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian's professional judgment. I accept responsibility for any result in additional charges. I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital). In the event of an unforeseen emergency, we will attempt to reach you without delay. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached.
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Please PROCEED with life-saving measures. I accept responsibility for all costs incurred.
Please DO NOT PROCEED with life-saving measures. I accept responsibility for all costs incurred.
I have read and understood the information printed above. Please sign below.
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Date
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Month
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Day
Year
Date
Submit
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