Surgery Intake Form | Range Road

was Owner I

Owner Name: *

First

Last

Name of pet being presented for surgery: *

Pre-Op Bloodwork is highly recommended by the veterinarian for any procedure involving anesthesia. Results of these tests help tailor the anesthetic protocol to your pets needs. It also informs us of your animal’s health status, although does not cover all possibilities. The pre-op bloodwork fee is $102.00 *

I authorize Pre-Op bloodwork prior to sedation/anesthesia.
I do not authorize Pre-Op bloodwork
I had the bloodwork completed at my pets pre-surgery check

I understand that my pet may be sedated and/or anesthetized. Although every effort is made to make this procedure as safe as possible for my pet, there are inherent risks with anesthesia and surgery that may include the possibility of death. I am encouraged to discuss any concerns I have about those risks with the veterinarian. I will not hold the veterinarian, Veterinary Clinic or staff responsible in any manner and assume all risks. *

I understand

In the situation of an adverse event while your pet is hospitalized, every effort will be made to follow your wishes. In all cases we will make every attempt to contact you as soon as possible. Please select your preference: *

Basic CPR (I accept the costs associated-Starting at $250)
DO NOT RESUSCITATE

Please fill in the following information to ensure that we can provide the best care for your pet.

The last time your pet was at what time on which date? *

Has your pet experienced any vomiting in the last 24 hours? *

Yes
No

If your answer to the above question was yes, how long has this been going on for and how would you describe the vomit? (ie. vomiting food, bile, etc)

Has your pet experienced any diarrhea in the last 24 hours? *

Yes
No

If your answer to the above question was yes, how long has this been going on for and how would you describe the stool? (ie. runny, liquid, soft, etc)

If your pet is on any medications at this time please list them here:

If you listed any medications above, please list the last dose given for each medication below:

Would you like us to perform a complimentary nail trim while your pet is under anesthesia? *

Yes
No

If your pet is not already micro-chipped, would you like to have them micro-chipped during this procedure? There will be an additional $76 charge for the microchip. *

Yes
No

Will you be needing a cone for your pet today? A technician will happily provide you with an estimate at drop-off. *

Yes
No

If presented animal is being spayed there will be an additional fee per condition if your pet is mature, in heat, and/or pregnant. *

I understand
My pet is male so this does not apply

If presented animal is being spayed and is pregnant at time of procedure do you want us to:

Continue with spay
Call you to discuss
Stop the procedure (I understand that I will be responsible for payment for all services performed up to this point)

Best phone number to reach you at today: *

I agree that payment for all services rendered + GST will be paid upon my pets release from the Range Road Veterinary Clinic. *

I agree

I the undersigned am responsible for the above pet and have the authority to grant my consent to the hospitalization and treatment and/or operation upon my pet. After carefully reading the above form, please sign your agreement below: *

Digital Signature

Date of form completion (mm/dd/yyyy): *

mm/dd/yyyy