SURGERY ADMITTING FORM

PET HISTORY

Did your pet eat this morning? Yes______No______

Is your pet allergic to any drugs? Yes______No______What?______

Has your pet had any illness or injury in the past 30 days? Yes______No______What?______

Does your pet have any history of seizures? Yes______No______

Has your pet ever experienced any problems or reactions under anesthesia? Yes______No______

Is your pet currently on any medication? Yes______No______What?______

PROCEDURE(S) TO BE PERFORMED:

Spay Neuter Declaw Other______

ELECTIVE PROCEDURES

Heartworm and tick disease test Dental cleaning

Feline leukemia and FIV testExtract deciduous (baby) teeth

Fecal examinationRemove dewclaws

Express anal glandsHome Again microchip

Clean and flush ears

Remove wart or skin growth Location______

Other procedure(s) you would like your pet to receive today______

OWNER AUTHORIZATION AND RELEASE

______Your pet will receive a pre-surgical blood screening prior to anesthesia and will be monitored closely with an ECG monitor

(initals) during surgery – routinely taking heart rate, blood pressure, oxygen levels and temperature. If an emergency arises, all efforts will be made to contact you. If we are unable to contact you, we will continue with the necessary emergency procedures, which may include but not be limited to injectable medications, IV fluids, oxygen therapy, and diagnostic

tests. There will be additional charges for these procedures.

You are to use all reasonable precaution against injury, escape, or death of my pet. I understand that all sedation/anesthesia involves some risk to my pet (such as unknown internal physical abnormalities, medication allergies, surgical complications, internal bleeding, shock, incision dehiscence, and post-surgical infections) and agree to hold you harmless, in the absence of negligence, in connection with these procedures. I acknowledge that no guarantee or assurance has been made to me as to the result that may be obtained. In the event complications arise and I cannot be immediately contacted at the phone number listed below, you are directed to make the decision you deem best for my pet. I agree to pay for services rendered.

I understand that Blair Doon Veterinary Hospital is not staffed 24 hours a day.

I have read the foregoing, understand what it says, and agree.

______

Owner’s NamePet’s Name

______

Signature (Owner/Agent)Date

PHONE NUMBER(S) WHERE I CAN BE REACHED TODAY______

LASER THERAPY has been shown to reduce pain and speed healing time post-surgically. Would you like laser therapy performed on your pet’s incision after surgery? Yes____ No____

IV ACCESS done pre-surgically makes for a quicker response time if there is an emergency during surgery. Would you like an IV started? Yes____ No____ Revised May 2015

Yes____ No_____ Revised May 2015