Thank you for dropping off your pet with us today! The following information will be used to help our veterinary team accurately complete your pet's medical history for today's visit.

Owner's Name *

First

Last

Pet's Name *

Species *

Dog
Cat

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

Who will we be speaking with today? *

Me
Someone else

Name *

First

Last

Primary Phone *

Secondary Phone

Email *

Car Make, Model, and Color that you will arrive/arrived in *

Surgical Procedure(s) (check all that apply):

You will be asked to fill out a Mass Removal Chart when you bring your pet in for surgery.

If other, please specify *

In-Patient Questionnaire

When did your pet last eat? *

When did your pet last drink? *

Is your pet showing any signs of illness? *

Yes
No

If yes, please explain *

Please list any past surgeries

Has your pet had any reactions to drugs/anesthesia/vaccines? *

Yes
No

If yes, please explain *

Current medications (please state last dose given, including preventions)

Please note: If your pet has fleas, they will be given a Capstar at your expense.

List any behavioral concerns (biting, timidness, needing special handling, etc.)

List any belongings with your pet today (please know that any items may be lost while your pet is here, and we recommend not leaving belongings)

Extractions

Dental Cleaning: During our dental exam and dental radiographs while your pet is under anesthesia, we may find teeth that need to be extracted. A known, yet non common complication of tooth extractions can be jaw fracture *

You have my permission to take any teeth that need extraction.
I would like a call before any extractions are done.
I decline ALL extractions.

** Please keep in mind when we have to call during the procedure, your pet is subject to prolonged anesthesia. If you cannot be reached and your consent cannot be obtained, we will not extract any teeth and your pet will need to have an additional dental surgery scheduled for a future date **

Extractions

Biospy Reports: We always recommend sending masses out for diagnosis. Results may change treatment plans drastically. It may take anywhere from 5 to 7 business days once the lab receives the sample to get a report. Your doctor will review the report and someone will call you with any findings. *

You have my permission to send out for biopsy.
I would like a call before any biopsy is sent off.
I decline sending out the biopsy.

**Standard Biopsy for One Site is $346.48. If there are multiple sites that need to be sent off there will be an additional cost.**

Blood Work & Additional Services

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.

Please select one of the following *

Full Chem, CBC, and Lytes - $195
Partial Chem, CBC, and Lytes - $167
I decline blood work and I understand there are increased risks during anesthesia (if anesthesia is needed).

Full Chem, CBC, and Lytes - $195

Full blood work on all major organs, full red and white blood cell count, and electrolytes
Indicated for longer anesthetic procedures and sick patients.

**Note – 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.**

Partial Chem, CBC, and Lytes - $167

Basic internal organ screen (liver, kidneys), full red and white blood cell count, and electrolytes
For generally healthy, younger patients.

**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**

CPR Consent

CPR Consent: I, the owner/agent understand that the therapeutic, anesthetic, or surgical procedures provided for my pet today involve the risk of complications, injuries, or even death, from both known and unknown causes. Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency medications, and other heroic interventions, I request that the doctor(s), staff, and Island Pet Veterinary conduct/do not conduct such medical care as indicated below. If I request said emergency procedures, I agree to be held financially responsible for veterinary services provided to my pet while staff members try to reach me for further directions. Regardless of my pet’s recovery or survival, I agree to pay CPR fees in addition to other fees already identified by the practice and agreed upon by me. *We will administer CPR treatment unless declined.* *

I agree
I decline

Additional Tests/Services

Select the below additional services you would like your pet to receive:

Authorization

I, the owner/agent of the pet described above, hereby consent to and authorize the performance of such procedures and accept financial responsibility for any resulting additional charges. I understand my pet will be going home with pain medications prescribed by the veterinarian, and these medications are NOT optional.

I understand payment is due in full at the time of my pet's discharge and agree to be responsible for any and all charges incurred. If for any reason, my pet may need to be hospitalized overnight, I understand that I will be referred for overnight care at the Swansboro Emergency Hospital and that I will be responsible for the transportation of my pet.

Signature *

Clear Signature

Date *

Surgery Admission Form

We can’t wait to see you!