7732 MacArthur Boulevard
Shanthi Ramachandran, VMD, MS
Cabin John, MD 20818
Apryl Reidelbach, DVM
phone: 301.229.2400
Alice Sartain, DVM
Fax: 301.229.2708
Email: info@vetalpine.com
Your name:
blanks
*
Your pet's name:
blank
*
The best number to contact you at today:
Phone Number
*
Is your pet being dropped off for surgery or other care?
Surgery
Other care
Urgent care
In certain urgent care situations we may need to recommend care available at a 24 hour or referral hospital.
What surgical procedure is your pet coming in for?
*
Spay (female)
Neuter (male)
Dental Procedure
Growth Removal
What are you dropping your pet off for?
*
Sedated wound care
Sedated exam or diagnostics
Drop off exam for sick pet
Drop off exam for routine care
Drop off for diagnostic testing - blood work, radiographs, etc
Please describe the number and location of growths.
*
When you drop off your pet, a staff member will confirm the growths to be removed with you
For a surgical procedure, your pet should have no food starting at 8PM the night before and water should be limited to small quantities. If your pet has food or large amounts of water in their system, we will be unable to proceed with the surgery.
*
I understand and my pet will be fasted for the procedure.
There is some complication with fasting my pet and I will call the office for specific instructions. (for example - medication instructions require food, diabetic patient, etc)
You have indicated your pet is coming for a service that does/may require injectable sedation. If scheduling in advance we request that your pet have no food the day of the appointment. If scheduling day of we request that you fast your pet to the degree you are able, but this may impact our ability to proceed. Please indicate when your pet last ate.
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
If your pet is coming in for diagnostic testing please select all that apply:
My pet will have last eaten the night before
My pet will eat the day of the appointment
My pet will have medication the night before
My pet will have medications on the morning of the appointment
When will or has your pet last eaten prior to drop off?
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
When will or has your pet last been medicated prior to drop off?
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
What medication did they receive prior to drop off?
Name of the medication
Dosage (strength of medication and how much you give of it)
1st Medication
2nd Medication
3rd Medication
4th Medication
5th Medication
For a sedated procedure, your pet should be fasted.
*
Is your pet eating normally?
Is your pet drinking normally?
Is your pet urinating normally?
Is your pet passing stool normally?
Are there any other concerns you'd like the vet to be aware of for your pet?
Is your pet on any medications or supplements?
*
Yes
No
Only heartworm and/or flea and tick preventative
What medication is your pet on?
Name of the medication
Dosage (strength of medication and how much you give of it)
How often do you administer this medication?
When did your pet receive their most recent dose?
1st Medication
2nd Medication
3rd Medication
4th Medication
5th Medication
Is your pet on any medications? If so, please tell us what medications, when they were last given, and how much medication was given?
In the event your pet's condition warrants additional treatment, we will attempt to contact you at the number you submitted previously. If we are UNABLE TO CONTACT YOU we will do the following:
*
Perform any treatment deemed necessary by the veterinarian.
Perform only those treatments the veterinarian deems necessary for life saving purposes.
Do not perform any treatment, lifesaving or otherwise, except anti-anxiety or pain management until we are able to contact you.
Have you received an estimate for your pet's treatment today?
*
Yes
No - Please send me one
No - Please proceed
Are there any other services you would like us to perform if possible while your pet is with us today?
Microchip Implantation
Ear Cleaning
Anal Gland Expression
Nail Trim
Sedated Procedure Consent
I am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consent. I have been informed that there are certain risks and complications associated with any operation or procedure of this type. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures. I authorize the use of appropriate anesthesia and pain relief medication as needed before or after the procedure. I have been informed that there are risks associated with the use of any medication.
Medical Release
I am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consent. By signing below, I acknowledge that I have read and completed this form and I authorize Alpine Veterinary Hospital to perform the services indicated. I acknowledge that full payment is due upon discharge.
Please sign or initial below to indicate your consent to the information above, and to demonstrate that the information you provided is accurate to the best of your knowledge.
*
Clear
Submit
Should be Empty: