Client Name Patient Name Phone number for today Email Date of Surgery Surgical Procedure to be performed I prefer Text Message Phone Call updates on my pet's surgery status Pre-Surgical Questionare When was your pet's last meal? If female, is your pet pregnant or in heat? If Male, have both testicles descended? Current medications your pet is taking and when was the last dose given Has your pet ever had problems with anesthetic procedures in the past? Is your pet allergic to any medications? Is your pet current on vaccines? If yes, please present your pet's vaccine certificate (if from another veterinary clinic) To protect your pet and the other pets entrusted to our care, all animals admitted to the hospital must be current on vaccinations, administered by a veterinarian, in an effort to prevent them from contracting or passing along any illness while in our care. Proof of vaccination is required at the time of admission; if you do not have proof of vaccination we would be happy to contact the veterinarian who vaccinated your pet for you. If vaccines are not current or proof is not available, then we will vaccinate your pet while here. Recommended services offered by Locust Trace Veterinary Clinic The doctors and anesthesia nurses at Locust Trace Veterinary Clinic routinely utilize EKG, pulse oximeters, respiratory, and temperature monitors during all anesthetic procedures. In addition there are other recommendations that are offered under general anesthesia. Pre-surgical blood panel (This is MANDATORY for animals over the age of 6 years) A pre-op panel tests kidney, liver, and blood sugar functions, allowing for a safer anesthetic procedure. $48 Yes CBC (Complete Blood Count)-A CBC helps us determine if anemia, dehydration, infection, or clotting problems are present. $38 Yes Other Services offered under general anesthesia Nail Trim- $6 Yes Ear Cleaning- $11 Yes Microchip- $55 Yes Anal Gland Expression - $6 Yes ***Please note that any animal undergoing a surgical procedure will be administered post operative pain medication, and may be sent home with an oral regimen. This is a MANDATORY service to ensure quality patient comfort and care at an additional cost ranging from approximately $20 - $55*** FOR DENTALS ONLY In the event that the doctors deem a tooth/ teeth are in need of extraction, I hereby authorize the extraction of the tooth/teeth at additional cost. (estimated $18-$40 per tooth) I agree I agree SURGERY CRISIS TREATMENT AUTHORIZATION I understand that with every surgery there are inherent risks, including reactions to anesthesia. In the rare instances that my pet may have a medical crisis while under anesthesia, I hereby authorize Locust Trace Veterinary Clinic and its Doctors to perform whatever tasks may be necessary to ensure my pet’s health and recovery from anesthesia. I understand that depending on the nature of the crisis, the charges for these treatments can range anywhere from $50 - $200. I agree I do not authorize Locust Trace Veterinary Clinic to take any action towards the health and safety of my pet while under anesthesia unless authorized by myself via phone call. I will not be legally responsible for payment of any life-saving treatments done during this time without my consent. I agree I hereby authorize the staff of Locust Trace Veterinary Clinic to perform the above procedures for my pet. The nature of the procedure(s) has been explained to me, and I understand and assume responsibility for all risks included in the surgery(s)/treatment for my animal. At the time of discharge, I agree to pay in full for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. I agree I agree
