Did you call to make an appointment already?
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Yes
No
**Please call us at (301) 483-7080 to schedule your appointment prior to completing this form.**
Filling out this form does not mean your appointment has been scheduled, only when your appointment is confirmed over the phone by our staff. For dental appointments, we require a $100 deposit during the time of scheduling.
Owner Name:
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First Name
Last Name
Phone Number:
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Please enter a valid phone number.
Email:
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example@example.com
Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Appointment Date:
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Month
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Day
Year
Date
Animal's Name:
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Microchip Number (if present/known):
Species:
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Please Select
Dog
Cat
Breed:
Pet Color:
Sex:
Please Select
Male
Female
Is your animal Spayed, Neutered, or Intact? (We require most animals we see to be fixed before or during their visit for an additional cost)
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Please Select
Spayed
Neutered
Intact/Unaltered
Pet Age or Birthday:
Has your pet been seen by a veterinarian for dental problems before?
Please Select
Yes
No
Are you expecting extractions today? The prices on dental services can vary wildly from $185-$1200 depending on the needs of the patient. If you are expecting extractions, please provide a valid phone number(s) where we can contact you from 9am-3pm. If you do not answer, extractions may not be performed, pending the doctor’s judgment. We will call a second time usually within 5-15 minutes. There will be no refunds if the doctor does not perform the dental as desired by the client.
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Please Select
Yes
No
Are you expecting ALL of your pet’s teeth to be extracted today?
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Please Select
Yes
No
ONLY If you are expecting a Full Mouth extraction select yes
Are there any additional surgical procedures you would like to have addressed during this appointment, such as mass removals or spay/neuter? If your pet is not spayed or neutered, it must be spayed/neutered today pending Doctor approval. If your pet is not vaccinated for rabies or proof of vaccination has not been provided, it must be vaccinated while under our care.
Nail trims and ear cleaning are $10.00 each
Is your pet on any medications?
Does your pet have any other medical conditions?
We always recommend pre-op bloodwork for all our patients. We do not have the ability to perform same day full-panel bloodwork. Pre-op bloodwork is not required, but strongly recommended for older patients. By checking this, I understand I am declining pre-op bloodwork if it has not already been done
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Please Select
I decline pre-op bloodwork
I have had bloodwork done and have provided a copy
With owner consent, Spay Now records specific procedures for other doctors to use for training purposes. Photos are also captured pre and post-operation for our social media accounts. Do you authorize Spay Now to document your animal's stay for internal and external use?
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Please Select
Yes
No
Please read and sign:
Spay Now will provide postoperative surgical rechecks for our patients for no charge during our regular clinic hours. If any medications are needed, there will be a nominal fee. Please call or email us (301-483-7080 spaynowsurgery@gmail.com) if you have any concerns after surgery. If you elect to take your pet elsewhere for post-operative care, we cannot reimburse you for any costs involved.If your pet is not currently on flea or tick prevention, there is a chance your pet may come into contact with animals also not on prevention and could contract fleas. In this event, I understand Spay Now is not at fault and that I may have to purchase flea/tick medication.I hereby declare that I am the owner, guardian, or responsible party for the animal listed above. I consent to and authorize Spay Now Laurel to perform the above listed procedures on my animal. I also consent for Spay Now to administer medications and/or ear cleaning, nail trimming, and/or grooming/bathing/matt removal as deemed necessary or prudent. While I expect these procedures to be performed to the best abilities of the veterinary and staff, I understand that with any vaccination, medication, anesthesia, or surgical procedure there are risks, including drug and vaccine reactions, bleeding, infection, or anesthetic complications up to and including death. I expect that reasonable precautions will be used to ensure the animal’s safety and well-being while in Spay Now’s care. I agree to release and hold harmless Spay Now Laurel, its agents, employees, and volunteers from all actions, causes of action, damages, claims or demands, which I, my heirs, executors, administrators, or assigns or the animal’s owner may have against the above referenced releases, for any and all damages, causes, or actions and injuries known or unknown, which may arise as a result of the surgery or treatment received by my animals. I have read and agree to the above:
Signature
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Date
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Month
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Day
Year
Date
Spay Now closes at 4 p.m. The latest time you can pick-up your animal is 3:30 p.m. At 3:30 p.m. clients who have not arrived are charged with a late fee of $50, and charged $25 for every 15 minutes they are late after 3:30 p.m. With your signature, you acknowledge that you have read and understood our late fee policy, and will be responsible for arranging transport for your pet in a timely manner.
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