Name *

First

Last

Email *

Phone *

Emergency Phone Number

Pet Information

Pet's Name *

Species

Breed

Age/Date of Birth

Sex *

Male
Neutered Male
Female
Spayed Female

Pet's Medical History

Vaccinations up to date? *

Yes
No

On heartworm prevention? (DOGS) *

Yes
No

History of seizures? *

Yes
No

Do you agree to fast your pet for at least 12 hours prior to your 8:30AM check in time? *

Yes
No

Problems with breathing/respiration? *

Yes
No

Coughing or sneezing? *

Yes
No

REQUIRED VACCINATION(S): Is your pet's RABIES vaccination current? *

Yes
No

Surgery and/or Anesthetic Procedure

Please check which procedure your pet is scheduled to have (please check all that apply):

Other *

Type of eye surgery:

Type of orthopedic surgery: *

The most common complications include:

Swelling around or beneath the incision line.

Additional risk factors include: Pets that are obese incur higher risks and higher fees associated with their procedure. Although extremely rare, the most serious complications include: Anesthetic death, Excessive bleeding, Infection afterwards.

If there is an underlying problem that we are unaware of, the problem could worsen with the stress of anesthesia or the possibility of compromising any organs that may be having problems that we are unaware of. Below are some options to add to your pet's procedure to decrease risk and make procedures as safe as possible

Do you understand the risk factors associated with your pet's procedure today? *

Yes
No

Do you still want your pet to have the procedure today having been informed of these risks?

Yes
No

Please specify other procedure:

MASS REMOVALS ONLY

Is your pet having a mass removed today? *

Yes
No

If so, would you like to have it tested by a histopathologist? *

Yes
No

If declined, do you understand that a histopath is a laboratory test in which a sample of your pet's removed tissue is sent to a histopathologist to determine if it is cancerous? *

Yes
No

Do you also understand that if the sample is cancerous, the histopath will reveal the level of severity, characteristics and identifcation of the type of cancer as well as show if the cancer extends past the margins or if it appeared to be completely removed? *

Yes
No

Have you been told to monitor the area for regrowth? *

Yes
No

DENTALS ONLY

Is your pet having a dental procedure today?

Yes
No

The most common complications include:

Soreness along gumline which may also include bloody saliva

Additional risk factors include:

Pets that are obese incur higher risks and higher fees associated with their procedure. Although extremely rare, the most serious complications include: Anesthetic death

Has a staff member explained that tooth extraction(s) are very common in this type of procedure?

Yes
No

Has a staff member informed you that we like to save as many teeth as possible?

Yes
No

Do you understand that the veterinarian will only extract teeth that are very loose, diseased, or if they appear as though they may cause dental problems in the near future?

Yes
No

DOG OR CAT NEUTER ONLY

Does pet have both testicles descended?

Yes
No

If no, do you understand that there are additional risks to your pet such as increased surgery time and more invasive procedure which could result in additional complications that could put his health at risk? *

Yes
No

Do you understand that the increased time and skill necessary to perform this procedure will result in an added fee for the procedure of $ 50-150 based on location of testes and difficulty of procedure? *

Yes
No

DOG OR CAT SPAY ONLY

Is there a chance the pet is pregnant? *

Yes
No
Maybe

If yes or maybe, when was her last heat cycle? *

If yes or maybe, do you want to go ahead with surgery and spay her?

Yes
No

IN HEAT OR POSSIBLY PREGNANT DOG SPAYS ONLY

If yes, do you understand that there are additional risks to your pet such as increased bleeding and additional complications that could put her health at risk if we do the procedure today?

Yes
No

Has a staff member explained these risks to you?

Yes
No

Do you understand and accept that IV fluid therapy will be required and it is possible that you may be charged additional fees for the procedure because my pet is in heat or pregnant?

Yes
No

SURGICAL OPTIONS

The very best and most safe way to do it is to choose the package, which includes several of these options and gives you a discount while making the procedure as safe as possible.

Anesthetic Safety Screening (pre-anesthetic blood chemistry and CBC)

To check proper organ functions, oxygen carrying ability of blood, ability to fight infection, platelets for proper clotting, and to establish a baseline for future reference.

REQUIRED for pets over 7 years of age.

This test screens for pre-existing conditions that would increase risks associated with anesthesia. *

Accept
Decline

IV Catheter and Fluid Therapy (Included)

Maintain blood pressure, replace blood loss, speed recovery, administer life-saving drug in case of an emergency. *

I understand

Pain Management

More comfortable and faster recovery. Options:

Injection given prior to surgery discharge (included)

Injection given prior to surgery discharge

Accepted

Oral pain medication which will be sent home with your pet

Accepted

Fluoride Treatment

Helps strengthen tooth enamel, prevents decay, stimulates remineralization, desensitizes exposed enamel.

Accepted
Declined

Plastic Cone or Inflatable Collar

Send my pet home with a plastic cone
Sent my home with an inflatable collar
I will be providing my pet with a cone purchased elsewhere

A cone may seem shameful, but it helps avoid the chance of infection after surgery, usually caused by your pet licking on their incision site.

Safety and Comfort Package Discount ($25)

Applies if Anesthetic safety screening (bloodwork), IV catheter and fluid, and both pain management options are chosen

Applicable
Not Applicable

ADDITIONAL OPTIONS

Please select:

Heartworm Test/ 4DX test
Microchip
Other
None

Other

CONSENT FOR TREATMENT

I, the undersigned owner or agent of the owner of the pet identified above, certify that I am eighteen years of age or over and authorize the veterinarian(s) at this practice to perform the above procedure(s). 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. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:

The reasonable medical and/or surgical treatment options for my pet

Sufficient details of the procedures to understand what will be performed

How fully my pet will recover and how long it will take

The most common and serious complications

The length and type of follow-up care and home restraint required

The estimate of the fees for all services

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. I agree to pay 100% of the estimated fees, assume financial responsibility for the remaining fees, and provide payment via cash, credit card, or check at the time my pet is discharged from the hospital.

Yes
No

Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff

DOES have my permission to provide such treatment and I agree to pay for such services.
DOES NOT have my permission to provide such treatment and I agree to pay for such services.

In the event my pet is hospitalized beyond the first day at this facility, I understand that veterinary care during nighttime hours and/or weekends is provided at the discretion of the attending veterinarian. Continuous presence of personnel may not be provided during these hours.

Keep him/her at FORTY32 Animal Hospital for hospitalization.
Choice 4

If I desire that my pet have supervision when this facility is closed, I elect to

Pick up my pet and provide such care in my home, in which case I accept all risks of adverse effects
I have him/her transferred to a local emergency clinic where overnight veterinary supervision is available at my expense.

I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made. I have read and understand the nature of the above procedures and give my consent to proceed. *

I have read and agree

SOCIAL MEDIA: I give FORTY32 Animal Hospital permission to post pictures or video of my pet's surgery *

Yes
No

Signature *

Clear Signature

Today's Date *

Online Forms

Anesthesia/Surgery Consent Form