Surgical/Drop-Off form

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 last name: blanks* Your pet's name: blank*
The best number to contact you at today: Area Code* Phone Number*
What are you dropping your pet off for today? *

Spay - Female Neuter - Male Comprehensive Oral Health Assessment and Treatment - Dental Sedated Wound Care Sedated Exam Medical Shave Down Growth Removal Emergency Stabilization X-Rays as Necessary Blood Work as Necessary
For Growth Removal, please describe where the growth or growths are located.
When did your pet last eat? *
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? *
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.
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
Should be Empty:

Sedated Procedure Consent