Tender Touch AH - Canine Surgical Admission Form

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Tender Touch Animal Hospital
Canine Surgical Admission Form

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Date* This field is required.

Date

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Client Name

First Name

Last Name

Email

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Sales Pet Name

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Please leave the best number to reach you at and name an alternate authorized person that can make health decisions for your pet today in the event that we cannot reach you.

Phone Number to contact you

Alternate Person Name

Alternate Person's Phone Number

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Procedure(s) Elected to be performed today

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I authorize extractions of retained deciduous (baby) teeth as indicated (initials)

I authorize dental extractions as indicated by the doctor's exam and x-ray findings. An estimate will be provided. (initials)

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*An Elizabethan collar (cone) will be necessary to send home today at your expense (cost: $11.10-$24.50) unless you can bring one with you at the time your pet is discharged. (initials) *

*If evidence of fleas is found, your pet will be treated with a 30 minute flea kill product and additional 30 day prevention at a cost of $38-$47 per treatment dependent on size (5#-130#). (initials) *

*Deworming is strongly advised when fleas are present, we will treat as necessary at a cost of $27-$49 dependent on size. (initials) *

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*Vaccinations are required for all pets who are not currently protected. (initials) *

Vaccines required:
Vaccines recommended per lifestlye:

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Anesthetic Precautions and Additional Procedures

We require a physical exam of your pet prior to anesthesia. However some conditions, including liver and kidney disorders, are not detectable without blood tests. I understand there are special risks associated with anesthesia, especially in an older pet, and the doctor strongly recommends the following tests and procedures to minimize those risks for my pet.

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I Accept The Following Tests

Pre-Anesthetic Screen: This blood test detects major organ and blood clotting abnormalities, which may complicate the anesthetic and surgical procedure(s). (Mandatory for pets over 7 years old).
Cost: $139.00     (initials)

Blood Pressure: This test can reveal any evidence of hypertension, which may complicate the anesthetic procedure. (Mandatory for pets over 7 years old).
Cost: $33         (initials)

K-Laser Therapy: This procedure provides natural pain management, decreased inflammation and faster healing for your pet.
Cost:            (initials)

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Ova & Parasite with Giardia: A stool sample is collected and submitted to a laboratory for detection of intestinal parasites. Test results will be reported to you in 48 hours.
Cost: $62.35        (initials)

Microchip: Permanent identification for your pet.
Cost: $45.50        (initials)
(this fee includes registration for one year)

Neat Package: Includes: nail trim, ear cleaning, expression of anal glands and teeth brushing.
Cost: $42.50        (initials)

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Pear Tree Paw Print: This is a handmade impression that has been hand painted, personalized, glazed, and kiln fired that's as unique as a fingerprint.
Cost: $92.00        (initials)
Color option    text here      Upgrades    text here
Requests    text here

IF ANY HEALTH PROBLEMS ARE FOUND, FURTHER COST MAY BE INCURRED-YOU WILL BE CONTACTED.***
Authorization for Treatment of Cardiopulminary Arrest:
(initials)    "DNR" - Do Not Resuscitate. No resuscitative effort to be performed.
(initials)    CPR - Medical resuscitative efforts include airway support, ventilation, thoracic compressions, and drug therapy if indicated. $175.00-250.00.

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I understand that during the performance of the forgoing procedure(s) unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such actions as necessary and desirable in the exercise of the veterinarian's professional judgement. I also authorize the use of appropriate anesthetics and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. I have been advised as to the nature of the procedure(s) and the risk involved. I realize the results cannot be guaranteed.

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Owner Signature* This field is required.

Clear

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Date Date * Employee Initials (initial here) *

Tender Touch Animal Hospital Canine Surgical Admission Form

Anesthetic Precautions and Additional Procedures

Tender Touch Animal Hospital
Canine Surgical Admission Form