Surgery / Sedation / Anesthesia Form

Owner's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Secondary Phone

Email *

Pet's Name *

When did your pet last eat? *

Is your pet on any 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? *

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. *

Yes
No

Signature *

Date *

Please complete this form before your visit.

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