Medical History - Procedure

Your Full Name:

Your Pet's Name:

Appointment Date:

Phone # to contact you during the appt:

Email to send your invoice to:

Preferred contact method:

What Procedure is your pet undergoing:

Are there any additional issues to address or services requested:

Do you want your pet to be microchipped:

Are you aware of any issues or complications with a previous anesthetic procedure:

If you answered Yes to the previous question, please explain:

Current medications/supplements:

Have you been presented with an estimate of expected costs

Do you understand & approve of the estimate:

Any additional information or significant medical history the doctor should be aware of:

Any medication refills requested:

The morning of the procedure, we will need to obtain the following additional information:

When was the last time your pet ate?
When was the last time your pet drank?
What medications has your pet been given and when were they last given?
Have you provided documented consent for us to perform the procedure? (signed or emailed consent or website submitted consent)