Patient Surgery Information Form
Any questions? Please call us at 363-6363.
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Last Name
First Name
Patient's Name


PHONE NUMBER __________ where we may contact you today if further information is required.

What type of surgery is your pet scheduled for today? ________________________________

______________________________________________________________________________.
Has your pet eaten within the last 12 hours?    [ ]YES     [ ]NO

Have you given any medications to your pet today?   [ ]YES     [ ]NO

We highly recommend a pre-anesthetic blood panel to test your pets' ability to metabolize
and eliminate the anesthetic. Do you want the pre-anesthetic panel?
 (available at additional charge of $44.50)   [ ]YES     [ ]NO

Pets experience pain/discomfort for approximately 3-5 days after surgery. We strongly recommend a prescription pain reliever as a very effective way to limit your pet's discomfort.
Do you want pain medication for your pet? (available at additional charge)   [ ]YES    [ ]NO

If sutures are required, we strongly recommend that your pet wear an e-collar until sutures are removed in 14 days. This may prevent your pet from causing damage to the incision area and incurring additional treatment costs. If an E-collar is declined, the additional treatment costs will be the responsibility of the owner. Do you want an e-collar to take home for your pet?(available at additional charge) [ ]YES    [ ]NO

If your pet is having a lump removed today, we recommend that the lump be sent to the lab for histopathology (identification). We will have results in 5-7 business days.
Do you want the histopathology to be performed? [ ]YES    [ ]NO

      Histopathology for ONE lump ($134.00)
      Histopathology for TWO lumps ($181.50)

Is your pet current on vaccines (including kennel cough)? [ ]YES    [ ]NO

Do you give permission to perform dental extractions, including deciduous teeth, if deemed necessary? (Charges may vary) [ ]YES    [ ]NO

Would you like your pet Microchipped today? ($43.50) [ ]YES     [ ]NO

If your pet is being spayed, there will be an additional charge if she is IN HEAT or OBESE at the time of surgery. This additional charge is due to the increased surgery time required.

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Signature of Pet Owner
Date