Surgery Intake Form

Save time during your next appointment. Complete your required surgery intake form online from any device at any time before your visit.

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Surgery Intake Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet before your visit.

Client Name *

First

Last

Patient Name *

Phone number at which owner can be reached today or tomorrow: *

Additional number

Email *

After procedure:

Would you like us to text you after the procedure, or would you prefer a call? *

Text
Call

Anesthetic and surgical procedure to be performed: *

I, the undersigned owner or agent of the pet identified above, authorize the staff of Animal Medical Center to perform the above procedure *

I have read and agree

Have you given your pets any medications or supplements in the past week? *

Yes, Other medication(s), please specify below
No

When was the last time fed?

Any other concerns/allergies/procedures?

Anesthesia Consent

I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. *

I have read and agree

I authorize Animal Medical Center to administer sedatives and use general anesthesia on my pet for the services or procedure outlined in the associated treatment plan. I have discussed the plan for anesthesia with a veterinary professional to my satisfaction and am aware I may contact Animal Medical Center with my questions. I understand that anesthesia poses a risk to my pet, regardless of health status. In the event of unforeseen complications, I give permission for the doctors and staff to take reasonable measures in treating my pet and accept all charges that are incurred as a result of such action. *

I authorize

In the Event of Cardiac Arrest During Hospitalization (heart or breathing stops) *

I request emergency and life-saving procedures (including cardiopulmonary resuscitation) be performed immediately on my pet. I understand I will not be contacted prior to these actions and give permission for the doctors and staff at Animal Medical Center to take reasonable measures in treating my pet. I accept all additional charges that are incurred as a result of such action. I understand initiating CPR does not guarantee survival.
Do Not Resuscitate (DNR). I understand Animal Medical Center will do everything possible to keep my pet stable during hospitalization and/or the procedure. If my pet has unstable vital signs, our staff will perform necessary steps to stabilize him/her. However, if my pet suffers cardiopulmonary arrest (heart stops, breathing stops), the staff will NOT attempt CPR. I understand this will lead to death.

Please inital to confirm your authorization of the above *

Financial Options

I authorize Animal Medical Center to perform the procedure outlined in the associated treatment plan on my pet. I understand the itemized treatment plan is a good-faith representation of what will be performed during this procedure. If Animal Medical Center encounters any NON- EMERGENCY, unexpected complications, or medical conditions that require the treatment plan to be altered, every effort will be made to contact me as these issues arise. In the case the hospital staff is unable to contact me, Animal Medical Center will follow my instructions as outlined below. *

I authorize

If unexpected complications or medical problems arise during my pet's hospitalization and I cannot be reached at my contact phone number: *

Do not perform any treatment or diagnostic testing on my pet that was not outlined in the treatment plan presented to me today. I understand that in some situations, this decision may negatively impact my pet's health, and I take responsibility for delaying care. In making this decision, the doctors and staff at Animal Medical Center will not be held liable or responsible for the results of my decision. I understand that should I choose to pursue these recommendations at a later time, follow-up charges will apply in addition to today. Recommendations for unexpected additional services may change as my pet's clinical status changes.
Perform additional treatments/services deemed medically necessary by the attending doctor as detailed below. I understand these services were not listed on the treatment plan presented to me, and thus additional charges are my responsibility (due at discharge). Animal Medical Center Veterinary staff will make every attempt to contact me at the numbers I provided before proceeding with the additional services. Treatments/diagnostics that are purely elective, or that will not benefit my pet's immediate health will not be performed without my permission.

Please inital to confirm your authorization of the above *

Please select an option for an E-Collar *

Plastic & velcro: Clear/see-through, custom sizing for neck and length, velcro closure
Comfy Cone: Padded, some customization for neck size, XS-XL length, velcro closure
I have an e-collar already and I will bring it to the discharge appointment
Per the surgeon, this procedure doesn't require an e-collar

I am over 18 and understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life sustaining procedures. *

I give my permission [yes]
I do not give my permission [no]

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above. *

I have read and agree

Signature *

Clear Signature

Date *

Comment

Surgery Intake Form

Surgery Intake Form

After procedure:

Anesthesia Consent

Financial Options

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Location

Contact Information

Hours

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