Surgical Admission Form Surgical Admission Form Please provide at least 24 hours prior to appointment Dogs/Cats: Please withhold food and water 12 hours before your pet's admission appointment. For Exotics/Birds please call the hospital for withholding food and water instructions. Name * Name First Name First Name Last Name Last Name Pet's Name * Email * Are you or any family member experiencing any signs of COVID-19 illness like fever, cough, body-aches, or loss of taste or smell? * Yes No Have you been exposed to anyone knowingly with COVID-19 illness in the last 14 days? * Yes No Note:Masks are now optional to wear on the day of your appointment. Surgical Procedure to be performed * Is your pet on medication? * Yes No What kind? * When was it last given? * I, the undersigned owner or agent of the owner of the pet identified above, certify that * I am over eighteen years of age eighteen years of age or older and authorize the veterinarian to perform the above procedure(s). I am not over eighteen years of age eighteen years of age or older and authorize the veterinarian to perform the above procedure(s). I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction: The reasonable medical and/or surgical treatment options for my pet Sufficient details of the procedures to understand what will be performed How fully my pet will recover and how long it will take The most common and serious complications The length and type of follow-up care and home restraint required The estimate of the fees for all services Any necessary payment arrangements While I accept that all procedures will be performed to the best of the abilities of the veterinarian and the staff at this hospital, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff * does have (CPR) my permission to provide such treatment and I agree to pay for such services. does not have (DNR) my permission to provide such treatment and I agree to pay for such services. If you are human, leave this field blank. Next
