• SURGERY/DENTAL ADMITTING FORM

  • Date of Procedure*
     - -
  • Format: (000) 000-0000.
  • Procedure to be performed:*

  • PLEASE ANSWER THE FOLLOWING QUESTIONS:

  • 2) Is your pet on medication? (Including Monthly Prevention)*
  • 3) Is there any history of seizures, previous anesthetic problems, or drug allergies?*
  • 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.*
    • For Dentals 
    • Do you authorize tooth extraction(s) as the veterinarian deems necessary (May be an additional cost):
    • 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.
    • For Mass Removals 
    • Biopsy to identify the type of mass/growth being removed (Additional Cost)

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

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

    • 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.

    • Date*
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    • Should be Empty: