Surgery/Dental Intake Form

SURGERY/DENTAL ADMITTING FORM
Name*

First NameLast Name
Date of Procedure*

MonthDayYear
Date
Phone Number: *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet Name*
Breed*
Sex*
Age*
Procedure to be performed:*

SpayMass RemovalDentalNeuterDeclawOther
PLEASE ANSWER THE FOLLOWING QUESTIONS:
1) When did your pet last eat?*
2) Is your pet on medication? (Including Monthly Prevention)*

YesNo
If yes, please list all medications & when last dose was given
3) Is there any history of seizures, previous anesthetic problems, or drug allergies?*

YesNo
If yes, please explain
4) Choose one of the following in case of an anesthetic emergency. By checking CPR I understand that there is an additional cost of $200-$500.*

CPRDNR (Do Not Recesatate)

For Dentals
Do you authorize tooth extraction(s) as the veterinarian deems necessary (May be an additional cost):

YesNo
If the doctor finds that your pet needs additional work, x-rays, and/or extractions today we will call you on the phone number you provide at the end of this form. If you cannot be reached, please chose one of the following.

The doctor may perform the necessary services needed for my pet, including extractions & additional x-rays. Additional charges will be paid at discharge.DO NOT perform any additional services, including extractions. I understand that this may lead to additional anesthesia or cost in the future.

For Mass Removals
Number of masses to be removed:
Biopsy to identify the type of mass/growth being removed (Additional Cost)

YesNo
Mass(es) must be identified and clearly marked by a technician, at the time of drop off. (Initial)Owner blanks

Intake Form Continued...
While my pet is here, please perform the following procedures (at additional cost):

Exress anal glandsEar cleaningMicrochipPluck earsRemove retained baby teethNail Trim
Any additional requests while your pet is here
PLEASE READ AND SIGN BELOW:
- The person signing this form hereby certifies that he/she is the owner of the animal described above or that the pet's owner has appointed them as his/her authorized agent to arrange for the consent to the surgical and/or other procedure(s) for the pet identified.
- I hereby authorize the veterinarian and staff on duty to perform said procedure(s) on the pet, administer to the pet such pain relief medication, sedatives and/or anesthetics as they consider appropriate for the procedure(s) I authorize them to provide the pet such medical, radiological, surgical, diagnostic, and/or emergency care as they consider necessary or appropriate in connection with the procedure(s).
- A veterinarian or staff member has explained to me the procedure(s) and the risks associated with said procedure(s) I hereby acknowledge that I fully understand the risks, including the fact that the use of anesthesia as a part of the prcedure(s) may cause injury to my pet or in rare cases death. I also acknowledge and agree that the veterinarian cannot guarantee that the procedure(s) will be successful.
- As the owner or the owner's agent, I hereby agree to pay in full for the services rendered, including those deemed necessary for medical or surgical complications or for unforeseen circumstances. I understand that the estimate of costs for the procedure(s) is only an approximation and that the final invoice for the procedure(s) may be greater or less than this amount. I agree to pay the final cost in full before the pet is released to me; regardless of whether the procedure(s) was successful.
In the unlikely event that your pet stops breathing or heart stops beating, CPR will be performed unless otherwise discussed. I realize that even the most successful CPR may not restore him/her to good mental and physical health. Additional charges will be incurred.
Owner's/Agents signature*

Clear
Date*

MonthDayYear
Date
Contact Number*
Additional Comments
Should be Empty:

SURGERY/DENTAL ADMITTING FORM

PLEASE ANSWER THE FOLLOWING QUESTIONS:

PLEASE READ AND SIGN BELOW: