Client First Name*

Client Last Name*

Pet's Name*

Preferred contact method day of procedure*

Text Message

Phone Call

Phone Number where you can be reached on the day of the procedure*

Was an estimate provided to you?*

Yes

Do you have any additional questions to go over with the technician during the time of your pet's surgical check in?*

Yes

Pre-operative blood work is required for some procedures but is recommended for
all patients undergoing anesthesia. This blood work allows our team to assess
your pet’s anesthesia risk level and tailor the medications used accordingly. While
it is preferable to do it prior to the day of surgery, we can perform this on the
morning of surgery.

Canines Only: An up-to-date heartworm test is required for all dogs 1 year of age or older.
If your dog is overdue, we will update it on the day of surgery.

Pre-operative bloodwork is recommended for all surgical procedures. Has this already been performed for your pet?*

Yes

Vaccines needed?*

Yes

If no, this can still be performed in hospital, the morning of surgery if necessary.

Is your pet currently on any medications?*

Yes

If yes, list medications and when last given*

Canines Only: While recovering from surgery, it is important your pet has restricted activity for
10-14 days. If interested, we can send home medication (typically Trazodone) to
help keep them calm during their recovery period.

Canines Only: Sedation to go home?*

Yes

Prevention needed?*

Yes

Medication refills?*

Yes

A noninvasive therapeutic laser therapy is offered to all our surgical patients after
surgery over their surgical incision. This therapy helps decrease pain,
inflammation and speeds the healing process.

Laser therapy?*

Yes

Applies to Spay and Neuter Surgical Procedure:
Tattoos are applied to patients surgically spayed/neutered. Tattoos aid in the identification of altered animals for prevention of unnecessary surgical exploration in the future. This is performed free of charge.

Spay/Neuter tattoo?*

Yes

Dog and cat microchipping is a simple procedure. A Home Again microchip is a
permanent pet ID. It is read by passing a microchip scanner over the pet’s
shoulder blades. The scanner emits a low radio frequency that provides the power
necessary where the chip is located to transmit the microchip’s unique cat or dog
ID code and positively identify the pet.

Microchip?*

Yes

An Elizabethan collar (or e-collar) will aid in protecting my pet’s incision after
surgery and understand there can be serious complications if they lick or chew it
open. An abdominal incision may even be life threatening.

Do you need an Elizabethan collar (E-collar/cone) for recovery?

Yes

In the unlikely event that your pet experiences respiratory and/or cardiac arrest there is a
short and critical window of opportunity to initiate CPR beyond which the success rate of
cardio-pulmonary resuscitation decreases significantly.

If CPR is selected and necessary, we will contact you to make further decisions.

If CPR is effective, there are often problems that need to be addressed after resuscitation.
CPR does not resolve any underlying diseases. It is important that you know there are
costs associated with CPR and the total will vary depending on your animal’s needs. This
and the cost of any additional care after CPR are in addition to your current estimate.

Should you change your mind at any point during your pet’s hospitalization, please notify
your pet’s doctor so that we may follow your wishes. We will ask you to sign a new form
with your revised choice.

Would you like us to start CPR immediately or do you elect not to resuscitate (DNR)?*

CPR

DNR

I, the owner, have read and understand all of the above policies mentioned.

Signature*

Date*

Phone

This field is for validation purposes and should be left unchanged.

General Surgery Check-In