Recheck Exam Admission Form

APPOINTMENT
Complete this form if you’ve had an appointment within the last 30 days.

We will need to be able to contact you or someone with permission to make medical and financial decisions.

In order for our doctors to do a complete analysis for diagnosis, do we have permission to perform the following if needed?:

Please note: Pre-anesthetic blood work checks the internal organs and blood count and is a vital part of safe anesthesia. Help us provide the best level of care for your pet by choosing to perform blood work prior to anesthesia or sedation.

Full bloodwork an all major organs and full red and white blood cell count; indicated for longer anesthetic procedures and sick patients. *Required for pets over the age of 8 years old* NOTE – We may require this blood work for some procedures and situations
Basic internal organ screen (liver, kidneys) with full red and white blood cell count; for generally healthy, younger patients. *Required for pets over the age of 5 years old*
An estimate will be given if an ultrasound is needed.

I, the owner/agent for the pet described above, request and authorize an exam for my pet. I have read and understand all of the information listed in this form. I understand that the staff at Island Pet Veterinary will contact me at the number listed above after my pet has been examined to discuss diagnosis and treatment, and will have an initial estimate of charges.

 

I understand payment is due when my pet is discharged, however, a deposit may be required after an estimate is prepared and discussed. I accept financial responsibility for charges incurred for this pet.