Pre-Examination History and Consent Form

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Comments

This field is for validation purposes and should be left unchanged.

Date*

MM slash DD slash YYYY

Owner's Name*

First Last

Pet's Name*

Home Phone

Cell Phone

Work Phone

Which phone number should we use to contact you today?

Home

Cell

Work

Other

[If Other]*

If appropriate, would you prefer us to contact you via text message?

Yes [Valid cell number]

[Please inform a receptionist if your mailing address has changed]

Do you have Pet Insurance?

Yes

If “Yes”, which provider is your policy with?

Reason(s) for today’s visit

What brand of food do you feed your pet?

How much?

How often?

Has your pet eaten today?

Yes

[If “Yes”] What?*

[If “Yes”] What Time?*

Does your pet take any medications and/or nutritional supplements?

Yes

[If “Yes”] What kind and please write when it was given last?*

Type of Medication/Supplement

Time Given

Does your pet have any allergies?

Yes

[If “Yes”] What kind?

Do you use a flea/tick preventative?

Yes

[If “Yes”] What kind?

Does your pet have a microchip?

Yes

[If “No”] Would you like one implanted today?

(Cost of a Microchip Implant is $73.19)

Yes

Dog

Is your dog given heartworm preventative year-round?

Yes

[If “Yes”] What Kind?

[If “Yes”] Date last administered?

Will your dog be boarding in a kennel within the next year?

Yes

Does your dog do any of the following? (Check all that apply):

Hunt

Run/hike in the woods?

Have exposure to livestock urine?

Groom them self?

Come in contact with other dogs?

Cat

Does your cat go outside?

Yes

Has your cat ever been tested for leukemia or feline aids?

Yes

[If “No”] would you like your cat to be tested today?

Yes

Has your cat ever been tested for heartworm disease?

Yes

Is your cat on monthly heartworm prevention?

Yes

Dog or Cat

Has your pet exhibited any of the following signs, symptoms or behaviors? (Check all that apply)

Weight gain

Weight loss

Appetite increase

Appetite decrease

Vomiting

Diarrhea

Constipation/difficult defecation

Increased drinking

Decreased drinking

Soiling/Incontinence/dribbling stool or urine

Bad breath

Difficulty chewing

Drooling

Coughing

Sneezing

Wheezing

Gagging

Choking

Difficulty climbing stairs

Uncoordinated

Lameness

Stiffness

Decreased activity

Listlessness

Weakness

Muscle tremors

Shaking

Seizures

Unusual discharge

Body odors

Scooting rear end

Head tilt

Ear scratching/rubbing

Increase in grooming behavior

Decrease in grooming behavior

Itching

Scratching

Poor coat

Hair loss

Behavior change

Skin problems

Lumps or bumps? (Please note location on diagrams}

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Diagnostics and Treatment Consent

I hereby authorize Suffield Veterinary Hospital to perform professional services that are, in their opinion, advised for treatment and maintenance of my pet’s health and wellbeing. I also authorize the following, if necessary, to be performed:

Blood work

Please inital

X-Rays

Please inital

Sedation/Anesthesia

Please inital

Surgery

Please inital

Other Diagnostic Testing

Please inital

Pre-Anesthetic Blood Work Consent

If your pet is here for a procedure involving sedation/anesthesia, please read the following carefully and indicate your preference by signing below.

A complete physical exam will be performed prior to any anesthesia/sedation to assure your pet’s health and safety. Along with the physical examination, we strongly recommend a few simple laboratory tests to determine your pet’s ability to tolerate the procedure and assure that it is a low-risk patient. The screening includes a complete blood count and a chemistry profile. This will demonstrate your pet’s ability to metabolize the sedation/anesthesia properly.

*ALL PETS 5 YEARS AND OLDER MUST HAVE PRE-ANESTHETIC BLOODWORK DONE BEFORE ANY SEDATION/ANESTHESIA. EVERY DOG MUST HAVE AN ANNUAL HEARTWORM TEST PRIOR TO ANESTHESIA*

We have the latest in laboratory equipment/technology which makes this procedure quick, easy, and inexpensive. We are proud to be able to offer this benefit to our clients. There is an additional charge of $164.60 for the screening and we feel it is an important step to ensure your pet’s safety and level of risk.

Please initial below to give your consent to the pre-anesthetic blood work and to show that you fully understand that there will be an additional cost for the blood work, and that it is an assurance, not a guarantee of your pet’s suitability for anesthesia.

Yes

Please initial

Website and Social Media Release

I hereby grant Suffield Veterinary Hospital permission to use the likeness of my pets (s), should they so choose, in a photograph, video, or other digital reproduction in any and all of its publications, including website and social media entries, without payment, compensation, or any other consideration. I understand and agree that these materials will become the sole property of Suffield Veterinary Hospital. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my pet’s likeness appears.

Yes

Please initial

After Hours Pick-Up Policy

Please note our business hours and make sure to pick up your pet prior to closing. If you pick up your pet after we close, you will be charged a late pick up fee of $50.00. If you are more than 30 minutes late, your pet will stay overnight at SVH and an appropriate overnight charge will be added to your invoice, in addition to the $50.00 late fee.

Payment for Products, Medications and Services Rendered

I understand that the invoice resulting from my pet’s admission to Suffield Veterinary Hospital is to be paid in full at the time my pet is discharged from Suffield Veterinary Hospital. I will satisfy payment via the following method:

Cash

Check

Visa/MasterCard//Discover/American Express

CareCredit

Please Initial

I am the owner or agent of the aforementioned pet, am at least 18 years of age, and am competent to contract in my own name. I have read this document in its entirety before signing below and I fully understand all of the content in this document and its meaning. I fully understand the impact of signing this release.

Signature*

Date*

MM slash DD slash YYYY

Printed Name*

First Last

Name	Species	Breed	Date of Birth/Age	Color

Dog

Cat

Dog or Cat

Diagnostics and Treatment Consent

Pre-Anesthetic Blood Work Consent

Website and Social Media Release

After Hours Pick-Up Policy

Payment for Products, Medications and Services Rendered

Office Hours:

Our Veterinary Office

Request an Appointment

If so, please indicate new information below

Pre-Examination History and Consent Form

Dog

Cat

Dog or Cat

Diagnostics and Treatment Consent

Pre-Anesthetic Blood Work Consent

Website and Social Media Release

After Hours Pick-Up Policy

Payment for Products, Medications and Services Rendered

Office Hours:

Our Veterinary Office

Request an Appointment

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