Owner and Pet Information

Your name and last name: *

First

Last

Best phone number to reach you: (Patient update and incase of emergency) *

Email: *

Pet's Name: *

Procedure your pet is having done: *

In-patient Questionnaire

Last time patient ate: *

Last time patient drank: *

Is your pet lethargic? If yes, when did it start? *

Is your pet vomiting or having diarrhea?

No, they have normal stool and no vomiting:
Yes, they are vomiting and/or having diarrhea:

Please explain frequency of vomiting and last episodes: *

If pet is having diarrhea please explain:

Is your pet giving you reason's to believe they are unwell? If yes, please explain: *

Yes
No, they are healthy and acting like normal

If yes, please explain what you notice is abnormal for your pet:

Last dose of heartworm medication? *

Does your pet have seizure? *

Yes
No

If yes, when was their last seizure:

If yes, what seizure medication(s) are they on and when was the last dose?

Is your pet on medications or supplements? *

Yes
No

If yes to medications or supplements, please list them and when was the last time you gave them:

Has your pet had previous anesthesia procedures? *

Yes
No

Has your pet had anesthesia related complications? *

Yes
No

If yes anesthesia complications, please explain:

Has your pet had previous surgeries? *

Yes
No

If yes to previous surgeries, please explain:

I am the owner or authorized agent of the pet named above. I consent to having the sedation/anesthetic/surgical procedure described above. I authorize the use of sedation/anesthesia and other medication(s) deemed necessary by the veterinarian and I understand that hospital personnel will be employed in the procedure as directed by the veterinarian. By signing this form electronically, and clicking on "Submit Signature", you are agreeing to the terms stated herein. *

I have read and understand

I have been advised as to the nature of the procedure and all my questions have been answered. I understand there are always risks associated with any anesthesia/sedation procedure, even in apparently healthy patients. I have discussed all my concerns with the veterinarian. I understand the risks of anesthetic procedures include respiratory, neurological and cardiovascular complications, in rare cases it can unfortunately result in death. Surgical complications include soft tissue damage, bleeding, neurological complications, dehiscence, failure to heal and in rare cases death. Complication from both anesthesia and surgery can be short term and/or long term. No procedure is a guarantee of successful treatment or diagnosis. By signing this form electronically, and clicking on "Submit Signature", you are agreeing to the terms stated herein. *

I have read and understand

For the safety of my pet I understand that it may be necessary to provide medical and/or surgical treatments which are not anticipated. I hereby authorize the veterinarian and staff to perform these procedures and understand I will be responsible for the charges. By signing this form electronically, and clicking on "Submit Signature", you are agreeing to the terms stated herein. *