Centreville Procedure Drop-Off

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Procedure Drop-Off Form

Please fill out our Procedure Drop Off Form prior to your pet's surgery or dental appointment. If you have a scheduled appointment, you may drop off your pet between 7:30-8:00 am in the morning and return later in the day to pick up your pet after the surgery or dental procedure has been completed.

We are here for you, please call us at (703) 222-9682 if you have any questions.

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Owner Name* This field is required.

First Name

Last Name

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Owner Phone Number* This field is required.

Phone Number

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Owner Email* This field is required.

example@example.com

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Pet Information* This field is required.

Pet Name

Procedure Being Performed

Additional Services

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Procedure Date* This field is required.

Procedure Date

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Has your pet eaten today?* This field is required.

YESNO

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When and how much was your pet fed?* This field is required.

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Is your pet on Medication?* This field is required.

YESNO

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Medication Info* This field is required.Please List all Medications your Pet is Taking

Medication

Time Given

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Is your pet on a 2nd Medication?* This field is required.

YESNO

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Medication Info* This field is required.Please List all Medications your Pet is Taking

Medication

Time Given

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Is your pet on a 3rd Medication?* This field is required.

YESNO

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Medication Info* This field is required.Please List all Medications your Pet is Taking

Medication

Time Given

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Would you like us to implant a Home Again microchip?* This field is required.*There will be an additional charge for implanting the Home Again microchip.

YESNO

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FOR DENTALS ONLY: Owner pre-approves any necessary extractionsIf Veterinarian is unable to reach you prior to extractions, he or she will make appropriate medical decision(s) regarding removal of tooth/teeth, so procedure may continue.

YESNO

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If additional blood work is necessary for treating your pet today, do we have your permission? * This field is required.*Pre-anesthetic blood work is required for all surgical patients*

YESNO

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If x-rays are necessary for treating your pet today, do we have your permission? * This field is required.

YESNO

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If Sedation is necessary for treating your pet today, do we have your permission?* This field is required.

YESNO

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Agreement

I understand that the doctors and staff at Centreville Square Animal Hospital will use all reasonable precautions against injury, escape, or death of my pet. I understand that all anesthesia involves some risk to my pet and will not hold the doctors and staff responsible under any circumstances. I understand that I assume all risks.I give permission for my pet to be treated as described above and agree to be financially responsible.

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Signature* This field is required. By signing this you agree to the terms on the previous page. Thank you.