Veterinary Surgical Admission Form :: Generated By JQueryForm.Com

Surgical Admission Form

Pet's Name

Breed

I certify that I own the above described animal, and do hereby consent and authorize Doctors R.C. Riggs, D.L. Heidrich, T.J. Kyle and A.M. Baltzell or their associates to care for my pet. I understand that risks exist with the use of medications, testing procedures, anesthesia, and surgery. I am encouraged to discuss any concerns that I have about the procedures(s) and risks involved and I also understand results cannot be guaranteed.

Accept

Payments: I am aware that unforeseen events resulting from the procedure(s) will not relieve me from any obligation to all reasonable costs incurred. Furthermore, all fees due for the care and treatment of my pet will be paid in full the day that my pet is discharged from the hospital. In the event that I fail to pay these fees, I will be liable for the reasonable costs of collection, including court costs and attorneys fees.

Accept

Preanesthetic Bloodwork: This is an in-house blood screening to test liver and kidney values. It helps us to determine if your pet is a good candidate for anesthesia. There is an additional cost for this service.

Information

Yes

No

OPTIONAL for pets under 7 years old
REQUIRED for pets 7 years and older

Dental Patients

Please call for approval

Please call for anything over estimate (recommended)

Approval received at drop-off

FIV/Feline Leukemia/Heartworm Testing: This is recommended for all cats that have not yet been tested or any cat that goes outside, has had cat bite wounds, or is acting sick. There is an additional charge for this test.

Yes

No

Other Services: We can provide these additional services while your pet is under anesthesia for an additional cost. Please select the services you would like performed today.

Nail Trim

Anal Gland Expression

Microchip Placed

Estimate: Would you like an estimate of your pets charges for today?

I have received an estimate

I would like to be called with an estimate

I do not require an estimate

Vaccination: All pets must be current on vaccinations for entry to the Best Friends pet hospital. By submitting this form I agree that my pet is fully vaccinated. If vaccinations were performed by someone other than Best Friends, I will provide records of vaccination.

If my pet isn't up to date on vaccinations, Best Friends will need to vaccinate my pet for it to be admitted to the hospital. I understand there is an additional charge for this service. Best Friends will gladly provide me with an estimate with the costs if desired.

I hereby acknowledge that I have read and agree to the above terms and conditions.

Please sign your full name here to accept:

Contact Information where we can reach you today WHILE YOUR PET IS UNDER ANESTHESIA if necessary:

Primary Contact Name

Primary Contact Phone

Primary Contact Preference

Call Only

Call or Text

Alternate Contact Name

Alternate Contact Phone

Alternate Contact Preference

Call Only

Call or Text

Appointment Date

Leave empty if appointment not yet scheduled

Your form has been submitted. Thank You!