Feline Surgical Admission

1

Owner Name* This field is required.

First Name

Last Name

2

Patient Name:* This field is required.

3

Make/Model/Color of the Vehicle You are Driving Today:* This field is required.

4

What is the best phone number to reach you TODAY to discuss your pet's care?* This field is required.

Area Code

Phone Number

5

Secondary Phone Number

Area Code

Phone Number

6

Email

example@example.com

7

What is the best way for us to contact you today?* This field is required.

Phone

Text

Email

Other

8

Who are we authorized to release your pet to other than you?* This field is required.

9

Are you leaving any items with your pet (leash/collar/etc)? If so, please describe:* This field is required.

10

Please indicate the surgical procedure(s) we will be performing for you pet today:

Declaw - Two Front Feet

Spay/Ovariohysterectomy (Female)

Castration (Male)

Other

11

Please indicate any additional procedures requested today:* This field is required.

Veterinary Examination for other health concern

Vaccinations

Flea/Tick Treatment (required at your expense if your pet is found to have fleas or ticks)

Intestinal De-worming

Feline Leukemia/FIV/Heartworm Testing

Microchip Implantation

Other

12

If requesting a Veterinary Examination, please indicate your concerns:

13

If requesting Vaccinations, please indicate your pet's needs:* This field is required.

Rabies

Feline Leukemia and FVRCP (Calici/Rhinotracheitis/Chlamydia)

No Vaccines Needed - Up to Date/Records Can Be Provided

14

Does your pet have any existing health issues we should be aware of prior to anesthesia?* This field is required.

15

Does your pet have any known allergies or reactions to medications or vaccines?* This field is required.

16

When was the last time your pet ate?* This field is required.Pet's should be fasted at least 12 hours prior to anesthesia for their safety. If your pet has eaten, your pet's surgery may need to be rescheduled.

17

To the best of your knowledge, is your female pet pregnant or in heat?* This field is required.

No

Yes - definitely pregnant or in heat

Maybe - recently finished a heat cycle / could have been bred

18

What is the pet's current diet (including treats)? Please specify brand, if known.* This field is required.

19

Have you noticed any changes in your pet's appetite?* This field is required.

Increase

Decrease

No Change

20

Have you noticed any weight changes in your pet?* This field is required.

Increase

Decrease

No Change

21

Any changes in water consumption/thirst?* This field is required.

Increase

Decrease

No Change

22

Any increase in urination or accidents in the home?* This field is required.

Increase

Decrease

No Change

23

Any change in bowel movements?* This field is required.

Increase (Diarrhea)

Decrease (Constipation)

Normal / No Change

Unsure

24

Date of most recent vaccinations:* This field is required.Use best estimate if exact date is unknown. Rabies vaccinations are required for our surgical patients. A rabies vaccine will be administered to your pet at the time of surgery if proof of vaccine has not been provided.

25

Date of most recent intestinal de-worming treatment:* This field is required.

Use best estimate if exact date is unknown.

26

Date of most recent labwork (CBC, Chemistry, etc):* This field is required.

Use best estimate if exact date is unknown.

27

Is your pet receiving monthly flea and tick prevention?* This field is required.

No

Yes

28

If YES, when was your last dose of flea and tick prevention given?

29

If YES, what brand of flea and tick medication are you using?

30

Is your pet on any prescription medications? If so, what?* This field is required.

31

Is your pet receiving any over-the-counter supplements (vitamins, joint support, CBD, essential oils, etc)?* This field is required.

32

Does your pet have any known behavior problems or aggression issues (biting, separation anxiety, etc) that we should be aware of prior to exam?* This field is required.

An additional handling fee or sedation charge could be required. If sedation and anesthesia is declined, we may be unable to safely examine or treat your pet.

33

Procedures to be performed today as part of our standard Surgical Care Package include: pre-anesthestic total protein & hematocrit, a pre-surgical examination, pain medication, antibiotic injection, isoflurane anesthesia with cardiorespiratory monitoring, a complimentary nail trim, and overnight hospitalization.

Your pet is scheduled for a procedure that requires anesthesia. Before placing your pet under anesthesia, our staff will perform a complete physical examination to identify any medical concerns that could complicate the procedure and compromise the health of your pet. Because there is always a possibility that a physical exam alone will not identify all potential health problems, we strongly recommend that bloodwork be performed prior to anesthesia. While pre-anesthetic testing does not guarantee the absence of anesthetic complications, it will enable us to identify and manage relevant medical conditions in order to provide the best possible care for your pet.

34

Please indicate your choice for pre-anesthetic labwork from the available options below:

I decline all pre-anesthetic labwork and understand the risks of this choice.

Chem 10 Panel (Recommended for the apparently healthy younger pet). I understand there is an additional charge for this service.

Chem 18 Panel, Complete Blood Count, Electrolyte Panel (Recommended for senior pets over 7 years old and pets with medical issues). I understand there is an additional charge for this service.

35

Have you received an estimated cost or price quote for the procedures you are requesting today?* This field is required.

Yes

No

No, I would like an estimate before surgery today.

36

What was the estimated cost you were quoted for today's procedures?* This field is required.

37

For the safety of your pet and other animals in the facility, your cat must arrive for their appointment in an enclosed carrier. If you do not arrive with a carrier, a cardboard carrier will be supplied to you at your expense. Do you understand?* This field is required.

YESNO

38

If your pet is found to have fleas or ticks, a parasite preventative product will be applied to your animal and you will be charged the full cost of this product. Do you understand?* This field is required.

YESNO

39

CONSENT: I hereby authorize the doctors and staff of the Animal Clinic of West Plains to perform such diagnostic, therapeutic, and surgical procedures as described above. The nature of such services has been described to me to my satisfaction. I realize that there are risks involved with any anesthetic or surgical procedure, and that no guarantee or warranty can be made regarding the results or cure. I also authorize the hospital staff, in an emergency situation, to follow through with such procedures as are necessary for the wellbeing of my pet on a continuing basis until further communication with me. I have been given an estimate (if requested) and understand that it is an approximation of planned procedures and the final bill may be more or less than this amount. I understand that I assume financial responsibility for all services rendered and that my pet may not be released to me unless payment is received in full.

40

Signature of Owner/Agent* This field is required.

Clear

41

Date