Surgical Appointment Request Form

Thank you for choosing the Animal Hospital of Rowlett for your pet's veterinary care. This is our general anesthetic procedure request form.

This is step one of the surgery scheduling process. Once completed, one of our surgery coordinators will contact you via email with a confirmed date and time for the requested procedure. After the deposit is paid and the surgery date is confirmed, you will receive a form to consent to anesthetic along with an estimate and the option to select various add-ons.

Should you have any questions, you can contact us at consents@ahrdvm.com.

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

We typically reach out via email, please let us know if you prefer an alternative.*

Pet Name*

Species*

Patient Breed*

Weight*

Patient Age*

Surgery Requested*

Cat Neuter Estimate

Cat Spay Estimate

Dog Neuter Estimate

Dog Spay Estimate

Dog Dental Base Estimate, Extractions are Additional

Cat Dental Base Estimate, Extractions are Additional

If you selected dental with additional surgery, surgery only or orthopedic procedure, please elaborate on the the procedure requested*

Have you been given an estimate for the procedure already?*

For estimates prior to scheduling, please email consents@ahrdvm.com

Low Cost or Full Cost?

For low cost procedures pet must be under 50 lbs, under 3 years of age and not a squish-faced breed with no doctor preference.

Are there any dates in the next 30 days that you are unavailable to bring/pick up your pet from surgery? If no dates listed, we will schedule your pet for the next available date and your deposit will be forfeited if canceled, rescheduled or no-showed. For dentals: please also specify here if you want first available or October Dental Month promo.*

Doctor Preference*

Dogs must have a current exam, preoperative labwork completed in the last 90 days, DHPP, Rabies, Bordetella and Influenza vaccines and have a negative fecal in the last 364 days. Cats must have a current exam, preoperative labwork completed in the last 90 days, FVRCP, and Rabies. Orthopedic procedures must also have radiographs on file prior to the date of surgery.

Initials*

If you are ready to schedule, please submit this form with the deposit link that will follow after submission. The non-refundable surgery deposit will secure your appointment on the next available date that matches your above listed availability. Should the surgery be less than the deposit, you will be refunded the difference after the procedure is complete. The remaining balance is due the day of the procedure prior to discharge.

We accept cash, all credit cards, Care Credit and Scratchpay. We do not accept checks for surgery balances. You can read more about and apply for carecredit at www.carecredit.com and for scratchpay at www.scratchpay.com.

Client Signature*

Date*

Date