Surgical Admittance Form

Date:

Last Name:

First Name and Spouse:

Address:

Street Address:

Address Line 2:

City:

State:

Zip Code:

Animal:

Breed:

Color:

Age:

Sex:

Home Phone:

Cell Phone:

Work Phone:

Other Phone:

Laboratory Test Consent

Your pet is coming in for a procedure or surgery that requires anesthesia. Some pre-existing conditions may not be evident on examination and blood screening can help identify these conditions that could lead to complications.

Age Of Pet:

0-5 years of age (recommended) PLEASE SELECT ONE:

 YES, I want my pet to have a pre-surgical screen = CBC/Miniscreen/SDMA ($152)
 NO, I do not want my pet to have a pre-surgical screen.

6 -8 years of age and older, REQUIRED pre-surgical screening

 Please check = CBC/Miniscreen/SDMA ($152)

9 years of age and older Required

 Please check = cbc/General Health Panel/Lytes/SDMA ($194)

Additional Services PLEASE SELECT WHICH YOU REQUIRE*

 Elizabethan Collar ($6.50-$31)
 Microchip for identification ($60.08)
 File/grind nails ($27) Nails are trimmed free of charge.
 Other

Pet History

Please specify any other current vaccinations and whether you would like them updated today.

Is your pet on heartworm preventive?
 YES  NO

Did your pet eat this morning?
 YES  NO

Is your pet allergic to any drugs?
 YES  NO

Has your pet had any illness or injury in the past 30 days?
 YES  NO

Current medications?
 YES  NO

If yes which ones?

Checked in by:  Receptionist  Technician  Flea/Tick Check

As the owner or agent for the owner of the above-described animal, I hereby give my consent to Jensen Beach Animal Hospital to perform the following surgery and/or treatment

I understand that during the performance of the above-mentioned surgery and/or treatment, unforeseen conditions may be revealed that necessitate an extension of this procedure or a different procedure than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are determined medically necessary by the veterinarian of Jensen Beach Animal Hospital, LLC. Furthermore, I authorize Jensen Beach Animal Hospital, LLC to use any diagnostic or medical methods, including medications, which in the professional judgment of the veterinarian are deemed medically necessary for the treatment and maintenance of my pet's health. The nature and risks of such services and/or procedures have been described to my satisfaction. I realize ethically and professionally results and outcomes cannot be guaranteed. In the event of abandoning my pet, I authorize Jensen Beach Animal Hospital, LLC to humanely dispose of said animal as directed by the Florida statute concerning “Animal Abandonment”. All financial obligations shall be paid in full upon discharge from the hospital. Certain circumstances may require a deposit. Any animal have surgery at Jensen Beach Animal Hospital will be checked for fleas and ticks. Any animal found with fleas or ticks will be treated and the owner will be charged for a medicated bath and prevention. I hereby grant permission to JBAH to photograph myself and/or my pet and use such images in all forms of media for any an all promotional purposes including advertising, display, exhibition or educational purposes. I further understand that there will be no financial compensation to me.

Please Initial:

IF YOU HAVE ANY QUESTIONS, PLEASE ASK BEFORE SIGNING THIS FORM. THANK YOU.

Name of owner or agent:

Date: