Surgery/Procedure Admission Form

Date*

Surgery/Procedure(s) planned:*

Does your pet have any of the following clinical signs?

Coughing

Vomiting

Change in thirst

Change in energy

Skin lesions

Sneezing

Diarrhea

Change in urination

Change in appetite

Itchy skin

Other

Do you have any other concerns about your pet?

When did your pet last eat?*

List all medications your pet takes and the time they were last administered

Medication 1 and Time last Administered

Medication 2 and Time last Administered

Medication 3 and Time last Administered

Medication 4 and Time last Administered

Medication 5 and Time last Administered

Would you like a microchip to be placed today?*

Yes

My pet already has a microchip

Primary phone number where I can be reached today*

Secondary phone number

If there are questions and I am unable to be reached via phone during the procedure:*

I give the doctor permission to decide on my pet's best interest.

I DO NOT give the doctor permission to perform necessary procedures that were not already discussed with me and understand that this may mean that my pet needs an additional anesthetic procedure.

Approval for procedure:*

I acknowledge that I am the owner/authorized agent for this pet and give my permission for the above-listed procedure(s) to be performed on my pet