Call: 410-522-9090
Text: 410-522-9090
2304 Boston Street Baltimore, MD 21224
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Surgery / Sedation / Anesthesia Form
Please complete this form before your visit.
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Owner's Name
*
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Address
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*
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Secondary Phone
Email
*
Pet's Name
*
When did your pet last eat?
*
Is your pet on any medication?
*
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No
Medication Name
*
Medication Dosage
*
Medication Frequency
*
When was the last dose given?
*
When is the next dose due?
*
Add another medication?
*
Yes
No
Medication Name
*
Medication Dosage
*
Medication Frequency
*
When was the last dose given?
*
When is the next dose due?
*
Add another medication?
*
Yes
No
Medication Name
*
Medication Dosage
*
Medication Frequency
*
When was the last dose given?
*
When is the next dose due?
*
Is your pet microchipped?
*
Yes
No
If no, would you like them microchipped while they’re here?
*
Yes
No
Do you need any refills of heartworm/flea/tick prevention?
*
Yes
No
Will you be leaving anything with the pet?
(Ex: leash, collar, harness, toys, etc)
In the case of an emergency, would you like us to perform resuscitation? Please be aware that every effort will be made to contact you immediately in this situation.
*
Yes
No
I authorize life-saving measures up to:
*
$500
$1000
Unlimited
Please be aware that every effort will be made to contact you immediately in this situation.
I have read, understand and approve the estimate for my pets procedure.
*
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No
Signature
*
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Date
*
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