Pre-Examination History and Consent Form Please complete the information below so we can keep our records up to date.Owner’s Name:Pet’s Name:Today’s Date: Home Phone:Cell Phone:Work PhoneWhich phone number should we use to contact you today?HomeCellWorkotherexplain otherIf appropriate, would you prefer us to contact you via text message?Yes (valid cell number)No(valid cell number)Email Address: Do you have Pet Insurance?YesNoIf “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?YesNo[If “Yes”] What?What time?Does your pet take any medications and/or nutritional supplements?YesNo[If “Yes”] What kind and please write when it was given last?Does your pet have any allergies?YesNo[If “Yes”] What kind?Do you use a flea/tick preventative?YesNo[If “Yes”] What kind?Does your pet have a microchip?YesNo[If “No”] Would you like one implanted today? (Cost of a Microchip Implant is $63.36)YesNo Dog:Is your dog given heartworm preventative year-round?YesNo[If “Yes”] What Kind?[If “Yes”] Date last administered?Will your dog be boarding in a kennel within the next year?YesNoDoes 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?YesNoHas your cat ever been tested for leukemia or feline aids?YesNo[If “No”] would you like your cat to be tested today?YesNoHas your cat ever been tested for heartworm disease?YesNoIs your cat on monthly heartworm prevention?YesNoDog 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 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 Sedation/Anesthesia X-Rays Surgery 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 $85.60 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.YesNoSignature (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.YesNoSignature (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 RenderedI 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 Care Credit 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.SignaturePRINTED NAME:Date
