First Name (required)
Last Name (required)
Pets Name (required)
What procedure is your pet here for today?
When was the last time your pet ate?
Do you feel your pet is in good general health? If not please explain.
Has your pet had any problems with anesthesia in the past?
Problems with Anesthesia:
If so, please describe the frequency of the problem and when it began.
Did you leave any personal items with your pet today? If so please list them:
Please list any questions / concerns you have or any additional procedures you are interested in while your pet is here (ie. toe nail trim, vaccines, heartworm test, etc.).
Questions or Concerns:
Please leave a reliable phone number and/or the name and number of another person who will be responsible for making decisions regarding your pet, that can be directly contacted today. Please leave as many numbers and contacts as possible.
If your pet is not yet microchipped, would you like one implanted while he/she is under anesthesia?
Please understand that during the course of your pet's stay with us unforeseen conditions may arise that necessitate medical attention from our staff. If we are unable to reach you or your representative at any of the above numbers provided your signature here authorized the performance of such procedures as are deemed necessary by the veterinarian's professional judgment.
Veterinary service during nighttime hours, some daytime hours and/or weekends, is provided at the discretion of the veterinarian in charge. Continuous presence of personnel may not be provided during these hours. (California Code of Regulations Title 16 Section 2030).
All accounts are to be paid in full at time of pick up. If you, the owner are not the one picking up your pet, do you authorize someone to do so?
If this person is not financially responsible for your pet, please arrange for payment ahead of time.
An outpatient fee is assessed for all patients being dropped off for medical services. Thank You.