Thank you for dropping off your pet with us today! The following information will be used to help our veterinary team accurately complete your pet's medical history for today's visit.

Owner's Name *

First

Last

Pet's Name *

Species *

Dog
Cat

We will need to be able to contact you or someone with permission to make medical and financial decisions.

Who will we be speaking with today? *

Me
Someone else

Name *

First

Last

Primary Phone *

Secondary Phone

Email *

Car Make, Model, and Color that you will arrive/arrived in: *

Surgical Procedure(s) (check all that apply):

Mass Removal
Spay
Neuter
Other

If other, please specify: *

In-Patient Questionnaire

When did your pet last eat? *

When did your pet last drink? *

Is your pet showing any signs of illness? *

Yes
No

If yes, please explain: *

Please list any past surgeries:

Has your pet had any reactions to drugs/anesthesia/vaccines? *

Yes
No

If yes, please explain: *

Current Medications (please state last dose given, including preventions):

Behavioral Concerns (list them below)(i.e., biting, timidness, needing special handling, etc.):

List any belongings with your pet today (please know that any items may be lost while your pet is here, and we recommend not leaving belongings):

CPR Consent: I, the owner/agent, understand that the therapeutic, anesthetic or surgical procedures provided for my pet today involve the risk of complications, injuries, or even death, from both known and unknown causes. Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency medications, and other heroic interventions, I request that the doctor(s) and staff conduct/do not conduct such medical care as indicated below. If I request said emergency procedures, I agree to be held financially responsible for veterinary services provided to my pet while staff members try to reach me for further directions. Regardless of my pet’s recovery or survival, I agree to pay CPR fees in addition to other fees already identified by the practice and agreed upon by me. *We will administer CPR treatment unless declined.* *

I agree
I decline

Authorization

I, the owner/agent of the pet described above, authorize the above procedure(s) to be performed. I understand that it may be necessary for the health and safety of my pet to provide medical and/or surgical procedures not anticipated.

I hereby consent to and authorize the performance of such procedures and accept financial responsibility for any resulting additional charges. I understand my pet will be going home with medications deemed necessary by the veterinarian, and these medications are NOT optional.

I understand payment is due in full at the time of my pet's discharge and agree to be responsible for any and all charges incurred. I understand that no staff will be attending my pet overnight (any pets needing overnight care will be referred to an overnight facility).

Signature *

Date *

Surgery Consent Form

Surgery Consent Form

Your preferred Avon Park veterinary hospital.

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We proudly serve the pets of Avon Park, FL, and beyond.