Surgical Check In Form (Custom PDF)

Pet's Name*

Date of appointment*

Date

Time

Primary Contact Name*

First NameLast Name

Primary Contact Cell Number*

Please enter a valid phone number.

Secondary Contact Name

First NameLast Name

Secondary Contact Number

Please enter a valid phone number.

What flea and parasite control is your pet currently on?*

When was the flea and parasite control last given?

Has your pet experienced any changes in urination or defecation?*

YesNo

If Yes, please explain:

Has your pet experienced any changes in behavior?*

YesNo

If Yes, please explain:

Is your pet on any medications, supplements, or vitamins?*

YesNo

If yes, lease list all, and when they were last given

Is there anything else we should know before we see you and your pet?

Anesthetic and surgical procedure to be performed*

If your pet does not already have a microchip, would you like one implanted during the procedure?*

YesNo

I the undersigned owner or agent of the owner of the pet identified above, certify that I am eighteen years of age or older and authorize Crescenta Canada Pet Hospital to perform the above procedures. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is to be initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:

-The reasonable medical and/or surgical options for my pet

-Sufficient details of the procedures to understand what will be performed

-How fully my pet will recover and how long it will take

-The most common and serious complications

-The length and type of follow up care and home restraint required

- The estimate of the fees for all services

-Any necessary payment arrangements

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I agree to financial responsibility for the remaining fees and will provide payment via cash, check or credit card at the time my pet is discharged from the hospital.

Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, select the following answer: the doctor has/does not have my permission to provide such treatment and I agree to pay for such services.*

The doctor HAS my permission to provide such emergency treatment and I agree to pay for such servicesThe doctor DOES NOT have my permission to provide such emergency treatment

Our team at Crescenta Cañada Pet Hospital is here to help you care for your pet in the best manner possible. We are always here for you and your pet. Our veterinary team is committed to our values of Empathy, Compassion, Understanding and Open Communication. We ask that you partner with us and share in these values. We will not tolerate yelling, swearing or any type of abuse to our team. If something is not right, we want to help address it, in a respectful manner.

Sincerely,

The Doctors and Team at Crescenta Cañada Pet Hospital

I have read and fully understand the terms and conditions set forth above.

By signing below you are confirming your appointment. We look forward to seeing you and your pet!*

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