PETCARE Animal Hospital Surgery Request Appointment

SAGE WILL BE OUT OF THE OFFICE 9/12/21 TO 9/20/21. ANY RESPONSES SUBMITTED ON THESE DATES WILL BE RESPONDED TO 9/21/21. THANK YOU.

Hello! Thank you for wanting to schedule a procedure with PETCARE Animal Hospital.

If you are a new client, please do NOT fill this form out until AFTER you have been seen by one of our veterinarians - our surgery coordinator cannot schedule you until you have been established with our facility. If you are new to us, please call and schedule an examination with our front desk at 801-302-9061.

Are You A New Client? *

No Yes (Please Call and Schedule an Examination with the Front Desk - The Surgery Coordinator CANNOT Schedule You Until You've Been Seen by One of Our Veterinarians - FYI Surgeries are Currently Booking Out 2-3 Months)

Name *

First Name Last Name

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Please enter a valid phone number.

Doctor Preference *

No Preference Scott Matheson DVM DABVP (Canine & Feline Practice) Darin Emch DVM

Has This Pet Been Seen By PETCARE Animal Hospital? *

Yes No

Best Day(s) for Surgery (We Do Not Perform Surgeries on the Weekend & Only 1 Veterinarian Performs Surgery Daily) *

Tuesday (Dr Emch) Wednesday (Dr Emch) Thursday (No Spays - Dr Matheson) Friday (No Spays - Dr Matheson) No Preference

Surgery Needed *

Spay (Dr Matheson does NOT perform any spays) - Females Neuter - Males Dentistry Tumor / Mass / Cyst removal Canine Dewclaw Removal Puppies Tails or Dewclaws (must be between 3 days and 5 days old) --> PLEASE CALL THE OFFICE AND SCHEDULE WITH THE FRONT DESK STAFF Microchip Placement Other

Pet Name *

Species *

Gender *

Breed *

Pet Date Of Birth

Date

Or Approximate Age (Weeks / Months / Years)

Has PETCARE or Any Veterinary Staff Ever Had Difficulty Handling Your Pet Before (We Need to Know This Information So We Can Decide on Medications) or Has Required Muzzling/Sedation To Be Seen? *

Yes No

If Your Pet Has Required Extra Handling Before, Please Detail What Was Needed? (Example: Can Only Place Muzzle by Client, Needs a Prescription Medication Before Veterinary Visits, etc...)

Comments On Surgery Needed (if applicable)

Vaccination Record - All vaccinations must be up to date for surgical patients. For dogs, Rabies / Distemper Parvo (required yearly) / Bordetella / Canine Influenza are required. For cats, Rabies / Feline Distemper / Feline Leukemia are required for all procedures. If we do not have record on your pet, we will update them at your expense. VACCINATIONS MUST BE PERFORMED AT LEAST ONE WEEK PRIOR TO PROCEDURE. If you fail to provide current documentation, then the surgery coordinator cannot schedule any procedures until those are current. Thank you. *

Vaccination Status *

Vaccines done in the last year by a licensed veterinarian (can provide documentation) No vaccines done in the last year - I need to schedule an appointment to update them Has never been vaccinated

Bloodwork (Unless Performed in the Last Six Months of Surgery Date) is Required to Be Done at Least ONE Week Prior to Surgery. I Acknowledge The Surgery Coordinator Will Schedule Me to Have Bloodwork Performed At Least One Week Prior to The Procedure Date *

Yes

An estimate will be emailed to you at the time of scheduling.

Surgeries are performed Tuesday through Friday

Admit times are between 8am and 8:45am - the surgery coordinator will assign you a time between that time frame. If you are unable to admit your pet between 8am and 8:45am, you have the option of admitting the night before between 4pm and 5:30pm. There is NO additional fee for admitting the night before.

FYI: Most Procedures are Currently Booked out 2-3 months. You may also ask to be placed on the cancellation list if anything opens up sooner.

Our surgery coordinator, Sage, frequently works from home so please refrain from calling the clinic. You will receive a text from 801-302-9061 to schedule the procedure(s) within FIVE business days.

If you end up needing to reschedule your scheduled procedure, please fill out this form again to re-submit the request.

If you are submitting this form BEFORE being seen, we will reach out to you AFTER your appointment.

Have a great day!

- Sage S [Veterinary Nurse / Surgery Coordinator]

Signature: I acknowledge if I do not respond within SEVEN days of contact from Sage at PETCARE, my suggested time slot for my pet's procedure will be released/opened to others. *

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