Patient Admission and Consent Form

Owner Name: First and Last Name*
Phone Number:   Phone Number*   
Emergency Contact and Phone Number:   Emergency Contact Information*   
Pet Name:Pet Name*

Has your pet had any food or water since midnight last night?YesNo*
Please select if your pet has been CoughingWheezing   Breathing Hard   Vomiting   Diarrhea       

Do you want your pet microchipped?Yes   No*  
Are you aware of any allergies your pet may have?Yes   No*   
If yes please list:   Allergies   

Is your pet currently on any medications?Yes   No*   
If yes please list them and when they were given:Medications   
Has your pet ever had an adverse reaction to any medication?Yes   No  
If yes please explain:   Reaction to medications   

*Disclaimer*

• A topical treatment will be applied if there is any evidence of fleas, flea dirt or ticks at the owners expense.
• An Elizabethan Collar may be required for your pets comfort and protection after surgery. Prices may vary according to size.
• For the comfort of your pet, pain management is given for all surgical procedures. 

In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached.    Please PROCEED with extreme life saving measure. I accept responsibility for all costs incurred   Please DO NOT proceed with extreme life saving measure. I accept responsibility for all costs incurred*