Surgery Admission Form in Knoxville, TN | Hardin Valley Animal Hospital

Owner’s Name:

Date:

Pet’s Name:

Breed:

Sex:

Age:

REASON FOR VISIT:

Vaccination Reminders:

Is your pet on heartworm preventative?

Yes
No

Is your pet on any additional medications?

Yes
No

Please list:

Did your pet eat this morning?

Yes
No

Is your pet allergic to any drugs?

Yes
No

Please list:

Has your pet had any illness or injury in the past 30 days?

Yes
No

Please list:

Does your pet have any history of seizures?

Yes
No

Please Explain:

Has your pet had any previous anesthetic problems?

Yes
No

Please Explain:

Please note any vomiting, diarrhea, coughing, or sneezing

Please note any other specific problems

OWNER AUTHORIZATION AND RELEASE:

For the enhanced protection of our patients, a preanesthetic blood screening is performed on all pets prior to surgery. It is already included in the price of the surgery.

I Do
I Do Not

request the implanting of a MICROCHIP into my pet today. The cost of a microchip is $58.50.

*If any animal presented for hospitalization is found to have fleas, treatment will be initiated immediately at owner’s expense. If any female is found to be in heat, pregnant or obese at time of spay, there will be an additional charge of $43.26 added to the price of the surgery.

Hardin Valley Animal Hospital (HVAH) will use all reasonable precautions against injury, escape, or death of my pet. I understand that anesthesia and surgery always involve some risk to my pet (such as medication allergies, surgical complications, incision dehiscence, and post-surgical infections). I agree to hold HVAH harmless, in the absence of negligence, in connection with these procedures. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. In the event complications arise and I cannot be immediately contacted at the phone number listed below, I authorize HHVAH to make the best decision for my pet. I agree to pay for services rendered. . I understand that HVAH is not responsible for loss or damage to personal items left with my pet including but not limited to leashes, collars, bedding and carriers.

After examination by our doctor, we will contact you before any diagnostic tests or treatments are performed. Please be sure you are available to discuss these findings when the doctor calls so that your pet’s tests or treatments can be performed in a timely manner.

IN THE EVENT YOU ARE NOT AVAILABLE TO TALK TO THE DOCTOR AND YOUR PET IS IN NEED OF LIFESAVING MEASURES, THESE TREATMENTS OR TESTS WILL BE DONE AT THE OWNER’S EXPENSE.

Phone number where you can be reached today:

Signature:

Date:

Owner/Agent