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Surgery Patient Registration Form (3/5)
Procedures requiring anesthesia such as surgeries and dental cleanings are always associated with a certain amount of risk. In order to minimize that risk, please don’t feed your companion animal at least eight hours before the appointment and please answer carefully the following questions.
Name of your companion animal
*
First Name
Last Name
Species
*
Breed
*
Age
*
Gender
*
Intact female
Spayed female
Intact male
Neutered male
Color
*
Microchip number
What procedure is your companion animal getting today?
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What time was your animal companion's last meal?
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What medication(s) and/or supplement(s) is your companion animal currently taking? Please list all.
*
What flea/heartworm prevention is using?
*
Does your companion animal have any history of biting a person or another animal?
*
Is your companion animal having any vomiting or diarrhea?
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Is your companion animal having any changes in eating or appetite?
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Is your companion animal lethargic?
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Is your companion having any excessive or unusual coughing or sneezing?
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Is your companion animal experiencing any changes in urination or drinking?
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Is your companion animal itchy or shaking her/his head?
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Is your companion animal experiencing any pain, limping, or mobility issues that you know of?
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Does your companion animal have any allergies to medications or foods?
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Are your companion animals’ vaccinations up to date?
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Was there a heartworm test performed in the last year?
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Is your companion animal taking heartworm prevention?
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Has your companion animal been tested for worms in the last year?
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Has your companion animal had any illness/injury in the last year?
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Has your companion animal ever had a seizure?
*
Does your companion animal get table scraps?
*
Please provide information about your companion animals' living situation by indicating whether they primarily live indoors or outdoors:
*
Indoors Only
Outdoors Only
Indoors and Outdoors
I would like the following services for my companion animal, additional to the surgery/procedure fee:
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DHPP vaccine
FVRCP vaccine
Rabies vaccine
Bordetella vaccine
FeLV/FIV test
Microchip
Nail trim
Ear cleaning
Blood work
Urine test
Radiographs
Flea prevention
Other
I am the guardian (or authorized agent of the guardian) of the animal described above, and have the authority to execute this consent. I understand that some risk always exists with anesthesia and surgical procedures, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. I hereby authorize the use of anesthetics, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my companion animal. I have carefully read, and fully understand, this consent. The fees associated with these services have been explained to me, and I agree to pay such fees in full at the time my companion animal is released from the hospital.
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Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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