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 all orthopedic procedures. 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. It is best to have blood
work completed within 1 month of the procedure, but blood work completed
within 90 days will be accepted. 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.

Preoperative bloodwork is REQUIRED for all orthopedic procedures. Has this already been performed for your pet?*

Yes

Is your pet currently on any medications?*

Yes

If no, it will be performed the morning of surgery, in hospital

If yes, list medications and when last given*

While recovering from surgery, it is important your pet has restricted
activity. Restricted activity needed varies based on the orthopedic
procedure performed. In general, most orthopedic patients will have 8-12
weeks of post-operative activity restrictions. If interested, we can send
home medication (typically Trazodone) to help keep them calm during
their recovery period.

Sedation to go home?*

Yes

Platelet-Rich-Plasma, or PRP, is blood plasma that contains concentrated amounts
of platelets and growth factors. PRP is a non-surgical and advanced means of
providing high doses of the body’s own healing factors directly to the area where
they are needed. PRP can be used in and around joints to help with pain and
inflammation due to injury and/or arthritis. It can also be used to aid in wound
healing and surgical healing.

PRP?*

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

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.

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

CPR

DNR

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.

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

Yes

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

Signature*

Date*

Name

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Ortho Check-In