ORC Feline Surgical Admission

1

Owner Name* This field is required.

First Name

Last Name

2

Patient Name:* This field is required.

3

Make/Model/Color of the Vehicle You are Driving Today:* This field is required.

4

What is the best phone number to reach you TODAY to discuss your pet's care?* This field is required.

Area Code

Phone Number

5

Secondary Phone Number* This field is required.

Area Code

Phone Number

6

Email

example@example.com

7

What is the best way for us to contact you today?* This field is required.

Phone

Text

Email

Other

8

Who are we authorized to release your pet to other than you?* This field is required.

9

Are you leaving any items with your pet (leash/collar/etc)? If so, please describe:* This field is required.

10

Please indicate the surgical procedure we will be performing for your pet today:* This field is required.

Spay/Ovariohysterectomy (Female)

Castration (Male)

Other

11

Date of most recent Rabies vaccination:* This field is required.Rabies vaccinations are required for our surgical patients. A rabies vaccine will be administered to your pet at the time of surgery if proof of vaccine has not been provided.

12

Please indicate any additional procedures requested today. Additional costs apply:* This field is required.

Veterinary Examination for other health concern

Vaccinations

Flea/Tick Treatment (required at your expense if your pet is found to have fleas or ticks)

Intestinal De-worming

Feline Leukemia/FIV/Heartworm Testing

Microchip Implantation

Comprehensive Pre-Anesthetic Labwork (CBC/Chemistry/Electrolyte Panels)

NOTHING ADDITIONAL REQUESTED

Other

13

If requesting a Veterinary Examination, please indicate your concerns:* This field is required.

14

If requesting Vaccinations, please indicate your pet's needs:* This field is required.

Rabies

Feline Leukemia and FVRCP (Calici/Rhinotracheitis/Chlamydia)

No Vaccines Needed - Up to Date/Records Can Be Provided

15

Would you like us to trim your cat's nails today? This is a complimentary service.* This field is required.

Yes

No

16

Would you like us to notch the cat's ear today?* This field is required.

Yes

No

17

Does your pet have any existing health issues we should be aware of prior to anesthesia?* This field is required.

18

Does your pet have any known allergies or reactions to medications or vaccines?* This field is required.

19

When was the last time your pet ate?* This field is required.Pet's should be fasted at least 12 hours prior to anesthesia for their safety. If your pet has eaten, your pet's surgery may need to be rescheduled.

20

To the best of your knowledge, is your female pet pregnant or in heat?* This field is required.

No

Yes - definitely pregnant or in heat

Maybe - recently finished a heat cycle / could have been bred

21

If your female cat is found to be pregnant prior to surgery, how would you like us to proceed?* This field is required.

Complete the surgery as scheduled.

Do NOT complete the surgery. If my pet is already anesthetized, wake her up without spaying her. (Some costs will still be incurred)

Other

22

Are you able to provide any patient history on this cat? (including changes in diet, weight, urination/defecation, etc). We understand this information may not be available for stray/feral animals.* This field is required.

No

Yes

Partial

23

What is the pet's current diet (including treats)? Please specify brand, if known.

24

Have you noticed any changes in your pet's appetite?

Increase

Decrease

No Change

25

Have you noticed any weight changes in your pet?

Increase

Decrease

No Change

26

Any changes in water consumption/thirst?

Increase

Decrease

No Change

27

Any increase in urination or accidents in the home?

Increase

Decrease

No Change

28

Any change in bowel movements?

Increase (Diarrhea)

Decrease (Constipation)

Normal / No Change

Unsure

29

Date of most recent intestinal de-worming treatment:

Use best estimate if exact date is unknown.

30

Date of most recent labwork (CBC, Chemistry, etc):

Use best estimate if exact date is unknown.

31

Is your pet receiving monthly flea and tick prevention?

No

Yes

32

When was your last dose of flea and tick prevention given?

33

What brand of flea and tick medication are you using?

34

What most accurately represents your cat's lifestyle?

Inside Exclusively (uses litter box for eliminations)

Outside Exclusively

Both Inside and Outside

35

Is your pet on any prescription medications? If so, what?

36

Is your pet receiving any over-the-counter supplements (vitamins, joint support, CBD, essential oils, etc)?

37

Does your pet have any known behavior problems or aggression issues (biting, separation anxiety, etc) that we should be aware of prior to exam?* This field is required.An additional handling fee or sedation charge could be required. If sedation and anesthesia is declined, we may be unable to safely examine or treat your pet.

38

Procedures to be performed today as part of our standard Surgical Care Package include: pre-anesthestic total protein & hematocrit, a pre-surgical examination, pain medication, antibiotic injection, injectable anesthesia with cardiorespiratory monitoring, a complimentary nail trim, and overnight hospitalization.

Your pet is scheduled for a procedure that requires anesthesia. As part of our routine surgical package, we will use an injectable form of anesthetic. For an additional fee, you may opt for isoflurane anesthesia, a gas inhalant form of anesthesia. There are advantages to using the gas anesthetic, including a decreased risk of anesthetic complications and the ability to quickly recover your animal from anesthesia. Your technician can answer any further questions you may have regarding anesthesia options. If you opt for gas anethesia, we recommend the addition of a post-surgical pain-management injection for your pet's increased comfort.

39

Please indicate your choice for anesthesia from the available options below:* This field is required.

I decline isoflurane anesthesia and post-surgical pain medication. Please use your standard surgical protocol.

I approve the ADDITIONAL COSTS of isoflurane anesthesia for my pet's surgery and request that you administer my pet additional post-surgical pain medication. I understand that these procedures will incur extra costs above what was originally estimated for my pet's care.

40

Have you received an estimated cost or price quote for the procedures you are requesting today?* This field is required.

Yes

No

41

What was the estimated cost you were quoted for today's procedures?* This field is required.

42

We will provide you a specific cost estimate for today's procedures prior to completing your pet's care. If you cannot be reached within one hour, please indicate how we should proceed:* This field is required.

Proceed with your basic surgical package not to exceed the original amount quoted

Proceed with surgical care including all additional items requested in this form, regardless of if it is over my quoted amount or I have not received an updated estimate

Proceed with surgical care not to exceed the following financial limit:

Other

43

CONSENT: I hereby authorize the doctors and staff of the Animal Clinic of West Plains to perform such diagnostic, therapeutic, and surgical procedures as described above. The nature of such services has been described to me to my satisfaction. I realize that there are risks involved with any anesthetic or surgical procedure, and that no guarantee or warranty can be made regarding the results or cure. I also authorize the hospital staff, in an emergency situation, to follow through with such procedures as are necessary for the wellbeing of my pet on a continuing basis until further communication with me. I have been given an estimate (if requested) and understand that it is an approximation of planned procedures and the final bill may be more or less than this amount. I understand that I assume financial responsibility for all services rendered and that my pet may not be released to me unless payment is received in full.

44

Signature of Owner/Agent* This field is required.

Clear

45

Date* This field is required.

Date