EmailMe Form - Time Saver Form

Name of Veterinarian *
Dr. Baum
Dr. Carrillo
Dr. Plechner
Dr. Quel
Dr. Williams
Other - please write in below
Other veterinian name
Your Name *
First Last
Email *
Please re-enter your email to confirm:

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Subject *
Your Phone Number *
### - ### - ####
Your Pet's Name *
Today's Date *
MM / DD / YYYY
Date of Surgery *
MM / DD / YYYY
Alternate/Emergency Phone where you can be reached on day of surgery. *
### - ### - ####
Scheduled type of procedure *
Other than the scheduled procedure, are there any other treatments that you would like us to perform while your pet is under anesthesia? *
Yes
No
If yes, please check all that apply below.
Additional treatments
Growth Removal (price varies)
Check & Clean Ears ($64)
Check & Clean Teeth ($101)
Vaccines ($20 each)
Microchip ($61)
Nail Trim (no charge)
Shave Mats (price varies)
Other (Please describe below)
Other treatment -1
Other treatment -2
Catheter and IV Fluids ($114 additional): *
Yes
No
IV fluids are recommended because it helps reduce the risk of shock, stabilizes blood pressure, and aids in faster recovery from anesthesia. We highly recommend this for all pets, especially ones that are more than 5 years old or with multiple procedures.
Pre-Anesthetic Bloodwork *
Yes- Limited Blood Panel ($127)
Yes - Complete Blood Panel ($156)
Yes - Coagulation Panel (determines bleeding disorders - advised for major surgeries - $60.70)
No
Other - Please describe below
NOTE: Pre-Surgical bloodwork is recommended in order to help identify hidden diseases that could worsen or increase because of the risk of anesthesia. The limited blood panel is recommended for pets under 7 years old, and a more complete panel is recommended for pets 7 years and older.
Other - bloodwork. Please describe.
WOULD YOU LIKE YOUR PET TO RECEIVE AN INJECTION FOR PAIN RELIEF ($47 additional)? *
Yes, I would like my pet to receive an injection for pain relief.
No. I decline any additional injections..
Please leave it up to the Doctor's discretion.
If your pet is here for a dental procedure, do you authorize extractions? Price range $24 to $128 *
Yes
No
N/A - My pet is not sceduled for dental procedure.
*To be filled in on day of surgery - Did your pet eat this morning?
Yes
No
(It's fine if your pet ate this morning. We will perform the procedure later when his/her stomach has had time to empty. Please note: your pick-up time may be later.)
EMERGENCY

I authorize any emergency treatment only if the doctor deems it necessary for keeping my pet alive. Additional cost could range from $61.00 to $121.00 *
Yes
No
NOTE: IF YOU HAVEN'T BEEN GIVEN AN ESTIMATE FOR OUR SERVICES FOR YOUR PET, PLEASE TAKE TIME NOW TO REVIEW COSTS WITH US.

I AUTHORIZE THE USE OF DIAGNOSTIC PROCEDURES AND ANESTHETIC AGENTS AS DEEMED NECESSARY FOR THE SAFETY OF MY PET. I UNDERSTAND THAT EVEN AFTER PERFORMING THESE TESTS THERE IS STILL A SLIGHT RISK OF ANESTHETIC OR SURGICAL COMPLICATIONS OR EVEN DEATH THAT WOULD BE UNFORESEEABLE AT THIS TIME. I ACKNOWLEDGE THE PROCEDURES HAVE BEEN EXPLAINED TO ME AND I UNDERSTAND THE RISKS INVOLVED WITH ANESTHESIA AND SURGERY.
Signature *
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SIGNATURE OF OWNER/AUTHORIZED AGENT - Please sign your name using your mouse or stylus over the line above, to be initialed at time of drop-off on our printout of this form.
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