Surgery Drop Off Form

Surgery Drop Off Form

Please complete this form to provide important details for your surgery drop off.
Patient Information

Please provide the patient's details.
Patient Full Name*

First NameLast Name
Date of Surgery*

MonthDayYear
Date
Breed
Color
Birthdate/Age
Sex
Type of Surgery*
Person Dropping Off Patient

Details of the person responsible for drop off.
Full Name of Person Dropping Off*

First NameLast Name
Phone Number of Person Dropping Off*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient*
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Special Instructions or Notes
If your pet is under 7 years of age, we do not require bloodwork prior to the procedure, but we do recommend any patient going under anesthesia have bloodwork done prior to the procedure. Would you like your pet to have bloodwork done prior to the procedure?*
Your pet is having a procedure done today, we recommend pain medication for their comfort. Animals don't always show their level of pain, but we do know that every surgical procedure is painful. If you are concerned about medicating your pet at home, please speak with our staff about tips/tricks. Would you like your pet to have post-op pain medications?*
Post-Op Laser therapy can help with inflammation and healing times. We would recommend this therapy on all surgical procedures other than growth removals. Would you like for us to perform post-op laser therapy on your pet?
I certify that I am the owner of the above pet and I do hereby consent and authorize Twin Pines Animal Clinic and staff to hospitalize my pet and treat as the doctor deems necessary for the health and safety for the above pet while under their care.

If my pet, the above named pet, should injure itself in an escape attempt, become ill, or die while hospitalized, I will not hold Twin Pines Animal Clinic or staff responsible.

I do realize that I am responsible for payment in full for services provided at the time of discharge. If I fail to pay, I agree to pay all finance charges and/or collection and attorney's fees.

If I do not pick up my pet within five days of written notice (mailed to the adress written above) stating that my pet is ready to be released from the hospital, Twin Pines Animal Clinic will assume that the pet is abandoned and the clinic will dispose of the pet as they see fit. Abandonment does not free the owner of the obligation to pay in full.
Signature*
Should be Empty:

Surgery Drop Off Form

Patient Information

Person Dropping Off Patient