South Putnam Animal Hospital - Dog Surgery Form

Dog Surgery Form
Introduction
We are looking forward to seeing you and your dog for his/her surgical appointment. Please arrive between 9 and 9:15am. You will need to be present while the doctor performs your pet's physical examination, so allow about an hour for the admitting process.

In order to make your pet's admission to the hospital easier, we ask that you read the enclosed materials and fill out the forms ahead of time. The first two pages asks for information about you and your pet. If your pet has had any testing or vaccinations in the past, please fill in the information and bring copies of their medical records with you to the appointment.

Your Animal Welfare League certificate entitles you to get Rabies and Distemper vaccinations for your pet at a substantial discount, and we recommend these vaccinations for all dogs and cats.
- For dogs: We require a current heartworm test for all dogs prior to anesthesia. If your dog has not been tested and/or is not on monthly preventative, we will perform this test in the morning before surgery. If your dog has been tested within the last 12 months and is receiving heartworm preventative, please provide us with a copy of the medical records. There are 3 additional vaccinations which we offer for dogs which provide protection against Lyme disease, Leptospirosis, and Canine Cough. Please indicate which of these vaccines you would like for your pet on the appropriate form.
Also in your packet is a consent form for pre-anesthetic blood testing, which can be done here at the hospital prior to surgery, and is recommended to provide additional information about your pet's overall health. A fecal (stool) examination for intestinal parasites is important for both dogs and cats and should be performed at least once yearly.

We appreciate your time and patience in filling out the enclosed forms. The requested information will help expedite the admission process while ensuring the best possible medical care for your pet. Please be sure to bring the completed forms as well as your Animal Welfare League Certificate and a copy of your pet's vaccine history the morning of your pet's surgery. You can also fax these records to us ahead of time at (845) 628-1896 or email them to: frontdesk@spahvet.com.

Your pet should not have anything to eat after 8:30pm the night before surgery. Normal access to water is fine. Please do not hesitate to call our office with any questions at (845) 628-1834. We look forward to seeing you!
Sincerely, The Doctors and Staff
Client Registration
Client Name*

First NameLast Name
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse/Co-Owner Name

First NameLast Name
Spouse/Co-Owner Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Spouse/Co-Owner Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client Email Address*
example@example.com
YesNo
IN THE CASE OF EMERGENCY

and no one is reachable at the above numbers, please contact:
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Referral
FriendWebsite/InternetFacebookYelpPrevious ClientSign/Hospital LocationAnimal Welfare LeagueProfessional ReferralVerizon Yellow Page
Name of Referral
Phone # of Referral (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Photo Authorization
We sometimes take photos of pets while at the hospital. These photos may be used on our website or Facebook page. When published we may identify them by your pet's name only.
I wish to accept the photo policy and allow SPAH permission to use said photosI wish to opt out of the photo policy and do NOT give SPAH to use said photos
Payment
DiscoverCareCreditVisa/MastercardCheckCashAMEX
It is our policy to provide you with an estimate of charges for any case where in-hospital procedures are provided. A deposit may be required prior to treatment. All charges are due and payable when services are rendered. I acknowledge that I am over 18 years of age.
Signature*
Pet Registration Form
Pet's Name*
Pet's Birth Date or Age*
Breed*
Color*
FemaleMale
YesNo
For New Pet Owners
YesNo
Pet ShopShelterBreederOther
YesNo
How long have you had this pet?*
Additional Pet Questions
YesNo
If you have additional pets, list the type and number you have of each (e.g. dogs - 2, cats - 1, guinea pigs - 3).*
When were your pet's last vaccines given?*
Dog Medical History Section
Please enter the date of your DOG'S last vaccination and test:
Distemper/Parvo
Lyme
Canine Cough (Kennel Cough/Bordetella)
Leptospirosis
Rabies - Indicate 1 year or 3 year
Heartworm Blood Test
YesNo
Please list the type of heartworm prevention your dog is on (if you know).
Medical History For Your Pet List Above
Dates and types of surgeries your pet has had:
NoYesUnknown (new pet)
If yes, please provide details:*
Heartworm Blood Test and Vaccine Consent
A current heartworm test is required for all dogs prior to anesthesia. If you pet has not been tested and/or is not on monthly heartworm preventative, we will perform a test in the morning before his or her surgery. If your dog has been tested in the last 12 months and is receiving heartworm preventative monthly, please provide us with a copy of the medical records which state the test results and purchase of preventative medicine.

It is recommended that the vaccines/tests listed below be current. The above vaccines and tests are recommended on an annual basis except for the distemper/parvo and rabies vaccine which may have 1 year or 3 year duration depending on your pet’s vaccine history. If this is the first time your pet is receiving these vaccines, a follow-up physical exam and distemper/parvo will be required in 3-4 weeks. The lyme, canine cough, and leptospirosis vaccines will require a booster in 3-4 weeks with one of our technicians. An annual fecal (stool) exam to look for intestinal parasites (worms) is recommended for all dogs. We recommend that heartworm preventative be started after your dog has a negative heartworm test and that your pet receives it year round. Our receptionist will be happy to provide an estimate for any services you wish performed on the day of your pet’s surgery as well as for any needed follow-up care.
Distemper/Parvo VaccineRabies VaccineLyme VaccineCanine Cough VaccineLeptospirosis VaccineFecal ExamHeartworm TestHeartworm Preventative
Signature*
Dog's Name*
Today's Date*

MonthDayYear
Date
Pre-Anesthetic Blood Testing Consent
The health and safety of your pet is our greatest concern. Some medical conditions may not be detected by a physical examination, so we recommend blood tests to give us more information about your pet's health prior to anesthesia and surgery. By testing blood chemistries we can evaluate the status of your pet's major organs. Many anesthetic drugs are removed from the body by the liver and kidneys, so these tests are of particular importance. Hematology testing, which looks at the blood cells themselves, is also important. We measure red blood cells, which carry oxygen throughout the body, using a test called a packed cell volume (PCV).

These tests help us assess the health of your pet and the level of anesthetic risk. If any of the tests are abnormal, we will discuss our findings with you and may adjust the dose or type of anesthetic used, or even postpone surgery until further testing can be done. If all the tests are normal, while it does not guarantee that your pet will not have a problem with anesthesia, it does tell us that your pet is healthy and in a low-risk category. If you have any questions regarding the blood panel or anesthesia, please ask. The veterinarian or staff will be happy to answer them.
Please complete the above blood work prior to surgery on my pet. I understand that if my pet is a dog a heartworm blood test will be performed as well prior to anesthesia. If any abnormalities are found, please contact me at the phone number below:
YesNo
Signature*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
I have elected to refuse the recommended pre-anethstic blood work at this time, athough I do understand that if my pet is a dog, a heartowrm blood test will be performed prior to anesthesia.
Signature*
Help Your Pet Find the Way Back Home!

Microchip Consent
What is a microchip? Microchips are tiny chips about the size of a grain of rice that contain a unique identifying number. Veterinarians and shelters use a hand-held scanner to find the microchip under the skin of the pet and read the number.

Why microchip? Unlike collars and tags that can be lost and tattoos that may fade, microchips are a permanent ID that cannot be lost and never wears out. Most animal shelters and many veterinarians scan stray pets for microchips, which contain a unique number registered in a national database. Through this database, lost pets can be reunited with their families. In addition, pets that travel to foreign countries are often required to have a specific, international standard (also called ISO) microchip placed for identification purposes.

Who can be microchipped? Microchips can be implanted into cats and dogs of any age and size.

How is the microchip implanted? Your veterinarian implants the microchip under the skin over the back of the neck, between the shoulder blades, using a needle similar to the kind used to give vaccinations. Once inserted under the skin, the chip is safe from weather, erosion, and theft. It cannot be seen and has no battery. Once your pet has the microchip implanted, you then access the online database to register your pet's number and your contact information.

How do I get my pet microchipped? Just ask! At South Putnam Animal Hospital we use ResQ international standard (ISO) microchips. They can be implanted at any time - during a regular appointment or when a pet is anesthetized for another procedure. Many owners decide to have their pets microchipped when they are spayed or neutered. Before implanting the chip, we will first scan your pet to make sure they don't already have one - our scanner reads all brands of microchips. Once microchipped, your pet will have better chance at getting home if ever lost.
Yes, please administer a microchipNo, I am declining a microchp for my pet
Owner's Signature*
Today's Date*

MonthDayYear
Date
25% Reward

Receive a savings of 25% off your pet's microchip when it is administered at the time of his/her spay or neuter. Must present this page at the time of surgery admittance to receive savings.
Should be Empty:

Dog Surgery Form

Introduction

Client Registration

IN THE CASE OF EMERGENCY

Referral

Photo Authorization

Payment

Pet Registration Form

For New Pet Owners

Additional Pet Questions

Dog Medical History Section

Medical History For Your Pet List Above

Heartworm Blood Test and Vaccine Consent

Pre-Anesthetic Blood Testing Consent

Help Your Pet Find the Way Back Home!