Surgical and Anesthetic Admission Form

Fill out the fields below to share your pet’s history.

Your Name *

Authorized Person Bringing Pet in for Procedure:

Patient Name *

Date of Procedure *

Contact phone number for day of procedure? *

Your Email *

Have you or anyone in your household tested positive for Covid-19 in the last 14 days or been exposed to someone who has? *

Have you experienced unexplained coughing, fever, aching, loss of sense of smell or taste, and/or sore throat, in the past 14 days? *

Are we using a credit card that is already on file to pay for the visit (if not, please call our office to provide your credit card information)? *

All patients who undergo anesthesia will receive a physical examination with a doctor prior to anesthesia. Please describe any specific problems that you would like us to evaluate:

Blood work is required within 6 months for all patients undergoing anesthesia (Or sooner for some conditions). IV Catheter and Fluids are required for all patients undergoing general anesthesia. A small area on either front leg will be shaved for placement of the IV catheter. A monitoring device, which may require shaving a small area on the underside of the tail for placement of the pulse oximeter to help monitor your pet’s heart rate and oxygenation while under anesthesia. All of these items will be included in your pet’s care plan in the doctor’s direction. Please ask to see the care plan if it is not brought out to you. Initial to indicate Understanding and Consent: *

An Elizabethan Collar (yes, the cone of shame!) is recommended after surgery to prevent your pet from licking/chewing/damaging the incision. If damage occurs, and surgical repair is needed, this will be an extra expense. An e-collar may be purchased on the day of the procedure. Please select YES or NO for having the e-collar added to your invoice on the day of the procedure. *

Yes

For Sterilization procedures ONLY, a green linear tattoo can be made to identify your pet as sterilized, unless requested otherwise on this form. Please authorize by selecting YES or decline by typing NO: *

Yes

Monday	8:00 am	6:00 pm
Tuesday	8:00 am	6:00 pm
Wednesday	8:00 am	6:00 pm
Thursday	8:00 am	6:00 pm
Friday	8:00 am	6:00 pm
Saturday	CLOSED	CLOSED
Sunday	CLOSED	CLOSED