Business Account Patient Drop Off Appointment Form

Date of drop off

Date

Business Name

Your name

First NameLast Name

Your Phone Number

Please enter a valid phone number.

Animals Name

First NameLast Name

Species

If you selected other from above, please indicate the animals species below.

Surgery to be performed

Is the animal on any medications? If so please list name, dosage, and frequency here. *PLEASE INDICATE THE LAST TIME THESE MEDICATIONS WERE RECEIVED*

Is your pet eating normally? If no, please describe in detail below

When did your pet last eat?

Has there been a change in diet? If so when?

Does your pet have any allergies or food allergies? If so, list them here. If none, write none.

Is your pet drinking normally? If no, please describe in detail below

When did your pet last drink?

Please list any concerns that you have in as much detail as possible.

Name of the person to contact regarding the pet

First NameLast Name

Phone Number for contact listed above

Please enter a valid phone number.

All pets admitted to the hospital must be up to date on all necessary vaccinations and routine screenings. Any outdated vaccines or routine screenings will be performed today. You should have been advised whether or not fasting was required for your pet and for how long. Your pet will be admitted, weighed, examined, prepped, and then added to inpatient or outpatient procedure schedules. Please note that it is NOT a first-come, first-serve basis. If our doctors have any questions throughout your pet's stay, they will contact you at the numbers left on this form. Once all services are complete, you will be contacted with a pick-up time, and a veterinary technician will go over a summary of instructions for home care.

Signing below indicates you have been informed that your pet requires preventive or therapeutic care and hereby consent to the appropriate procedures described to you by staff veterinarians at this facility. Signing below indicates the following:

You understand that there are always some risks with any anesthetic procedures, and any concerns will be expressed to the veterinarian before the procedure is initiated. The risks may include decreased blood pressure, cardiac arrhythmias, apnea, body temperature variations (hyperthermia vs hypothermia), idiosyncratic reactions to a particular drug, prolonged recovery times, and death. Additionally, there may be complications related to the surgery or procedure itself. Complications can also occur after the procedure is completed. My signature on this form indicates that any questions have been answered to my satisfaction.

South Wilton Veterinary Group only uses the safest anesthetic protocols, and patients in our care are closely monitored by a nurse-anesthetist as well as monitoring devices including pulse oximetry, ECG tracing, blood pressure, respiratory monitors, and temperature monitors. All patients undergoing general anesthesia will receive pre-operative medications and intravenous fluids during the procedure. The type of anesthesia used is dictated by the age and health as well as the scope of the procedure.

Pre-anesthetic blood tests within 30 days before the procedure are required to help ensure the safety of your pet under anesthesia. These blood tests are used to evaluate the functionality of vital organs like the liver and kidneys, which need to be healthy to metabolize the drugs used during surgery.

A pre-anesthetic ECG is also performed to evaluate the health and function of your pet's heart. If any abnormalities are present, the procedure may be altered or delayed until issues are resolved.

I understand that an estimate of fees for the above will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered. I agree to pay a deposit of 50% of the estimated fees at the time of drop-off. I assume financial responsibility for the balance of the services rendered and agree to provide payment with a credit card, cash, Care Credit, or check when my pet is discharged from the hospital.

I, the undersigned owner or agent of the pet owner identified above, certify that I am eighteen years of age or older and authorize the veterinarians at this practice to perform the above procedures.

I understand and agree to everything stated in this document. Planned treatments for this pet have been explained to my satisfaction. I authorize South Wilton Veterinary Group to perform the scheduled service(s) and/or procedure(s) on this pet.

Date Signed

Date

Should some unexpected life-saving emergency care be required and the attending veterinarian is unable to reach you, the practice is authorized to perform the treatment selected below:

CPR (Cardiopulmonary Recessitation)DNR (Do Not Resuscitate)

In the event life saving measures are performed, you assume all financial responsibility for such care. You also understand that life-saving measures are not a guaranteed success 100% of the time.

Date Signed

Date

Business Account Patient Drop Off Surgery Form