Surgical Admission Form

Procedure Date

Procedure

Patient Name

Age

Breed

Color

Owner Info

Name

First Last

Phone (available 8-4pm for updates/questions)

Alternate Contact

First Last

Phone

Relation to owner

REMEMBER THIS PERSON NEEDS TO BE ABLE TO MAKE FINANCIAL / MEDICAL DECISIONS IN YOUR ABSENCE

ALL patients must have been examined within 12 months BY OUR VETERINARY STAFF and be CURRENT ON RABIES prior to the surgical procedure. If your pet has NOT been examined, a wellness exam will be performed. If your pet has been previously Rabies vaccinated and is currently due, the vaccination will be updated before the animal leaves our clinic. ALL ADDITIONAL SERVICES WILL BE YOUR FINANCIAL RESPONSIBILITY.

Patient Medical History

Are your pet's vaccinations current?

What veterinary clinic are the vaccines current at?

Has your pet been experiencing vomiting, coughing, sneezing or diarrhea recently?

Please describe

Is your pet allergic to any drugs?

Please list

Has your pet had any previous medical conditions diagnosed or treated?

Please describe

Is your pet taking any medication/supplements now?

Please list

Last medication dosage date/time

Did your pet eat this morning?

If the staff notice your pet showing signs of anxiety, do you consent to an anti-anxiety medication be given to your pet while here?

ATTENTION: If fleas are found on your pet while visiting our facility, we will treat the pet, as well as pets housed near it, at the affected pet’s owner’s expense.

Pre-Anesthetic Testing

Consent

I authorize the pre-surgical blood screens ($109). I agree to pay for this additional service. I understand and assume all responsibility for additional risks or complications resulting from my refusal to approve this blood screen for my pet’s safety.

Preanesthetic blood tests can provide evidence of organ dysfunction that was previously unknown/undetected, which may affect how the patient responds to and/or recovers from anesthesia. Because of this, Casselton Veterinary Service, Inc REQUIRES THIS TESTING FOR ALL ANIMALS WHO UNDERGO ANESTHESIA AND ARE OVER 7 YEARS OF AGE. The cost of testing is $109 above the cost of your pet’s procedure. We also strongly recommend screening pets under the age of 7 years.

Elective Procedures

I agree to pay for all additional services that I check.

# of months of Heartworm Prevention

# of months of Flea/Tick Preventative

Other

Consent to Perform Additional / Necessary Medical Procedures:

Often physical abnormalities are noticed while your animal is looked over by the veterinary staff prior to surgery. If we feel that additional care is needed, please choose one of the following:

Consent

Please perform ANY NECESSARY procedures, which are deemed veterinary recommended, at this time to prevent my pet from requiring an additional visit and anesthesia. NO CALL IS REQUIRED.

Consent

Please attempt to contact me / my alternate contact PRIOR to performing other procedures, but proceed if no one is available to answer your call, at the listed phone number(s).

Consent

DO NOT proceed if no one is available to answer your call, at the listed phone number(s). I understand that this may require an additional visit and anesthesia for my pet.

If you have any concerns or questions about your pet’s procedure please feel free to call the clinic at 701-347-5496 or talk to a staff member before leaving your pet the morning of the procedure.

Emergency Care Consent

Consent

I understand the above mentioned anesthetic procedure may involve risk of complications, injury, or even death, from both known and unknown causes. No warranty or guarantee of my pet’s safety has been expressed or implied by any staff member. All efforts will be made by Casselton Veterinary Service to avoid complications.

Please choose ONE of the following:

Consent

In the event of cardiac or respiratory arrest, I authorize the clinic staff to follow through with life prolonging procedures as are necessary for the well being of my pet on a continuing basis until further communication with me. TRY AND RESUSCITATE MY PET. I agree to pay for all additional services.

Consent

In the event of cardiac or respiratory arrest, I directed that life-prolonging procedures be withheld / withdrawn. I understand that this may result in the death of my pet. DO NOT RESUSCITATE MY PET.

**ALL ELECTIVE PROCEDURES MUST BE PAID FOR IN FULL UPON PATIENT DISCHARGE**

Consent

I AGREE that I am responsible for payment of the above procedures and treatments in full at the time of the discharge. If I neglect to pick up my animal within 5 days of written notice my pet will be considered abandoned. Abandonment / Death of My Pet DOES NOT release me of my obligation for payment of services rendered.

Consent

I further agree that in the case of non-payment, a finance charge of 1.5% per month (18% per year) will be charged and any collection or attorney fees will be paid by me. All NSF checks are handled by Federal Check Recovery. I hereby authorize Casselton Veterinary Service to perform the surgical procedure on my pet as described above. I agree to assume all financial responsibility for services rendered. My signature below constitutes that I have read and agreed to the above consent form and that I am the owner or agent for the animal described above and have the authority to execute this consent. I further agree that the procedure(s) have been (i) explained to my satisfaction, (ii) that I have all the information I desire, and (iii) that I have had the chance to ask questions.

I plan on paying my bill with

Consent

I authorize and consent to the performance of the procedure(s) along with the administration of anesthesia.

Owner Info

Patient Medical History

Pre-Anesthetic Testing

Consent to Perform Additional / Necessary Medical Procedures:

Emergency Care Consent

Casselton Location

Fargo Location

Boarding And Grooming – Fargo

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