Forms

Need to complete a new client or surgery consent form? Save yourself the paperwork at our hospital and use our convenient online forms instead.

New Client Form

Surgery & Anesthesia Consent Form

Drop-Off Consent Form

Boarding Consent Form

New Client Form

Name *

Name

First

Last

Address *

Address

City

State/Province

Zip/Postal

Home Phone

Cell Phone #1

Work Phone

Cell Phone #2

Email *

Employer

Employer Address

City

State/Province

Zip/Postal

Spouse/Co-Owner's Name

Spouse Co-Owner's Phone

Spouse/Co-Owner's Employer

Employer's Address

City

State/Province

Zip/Postal

Emergency Contact Name: *

Emergency Contact Phone: *

How did you hear about Animal Care Hospital?

Saw our Hospital

Website

Yellow Pages

Newspaper Article or Advertisement

OtherOther

Is there an individual we may thank?

Please note: Your privacy is important to us.
All information received in all forms and through other communications is subject to our Patient Privacy Policy.

Pet Information

Pet's Name *

Date of Birth/Approximate Age *

Species *

Canine (dog)

Feline (cat)

Breed *

Color/Markings *

Sex *

Male

Male/Neutered

Female

Female/Spayed

Vaccinations were last given by (clinic name): *

Date last given: *

Add another pet Remove a pet

All payments are due at the time of services rendered.

I have read and understand the above statements and agree to all terms therein. *

I understand

Signature *

Clear

Today's Date *

Captcha

If you are human, leave this field blank.

Surgery & Anesthesia Consent Form

Anesthesia & Surgery Consent Form

Name *

Name

First

Last

Email *

Patient's Name *

Date of Birth

Feline

Declaw Only

Ovariohysterectomy (Spay)

Orchiectomy (Neuter)

Spay and Declaw

Neuter and Declaw

Dental Cleaning

OtherOther

Canine

Ovariohysterectomy (Spay)

Orchiectomy (Neuter)

Dental Cleaning

OtherOther

Medical History - Does your pet have any of the following? Please check all those that apply.

Deciduous (Baby) teeth

Diabetes

Bleeding Disorder

Respiratory Condition

In Heat

Hernia(s)

Recent Heat Cycle

Pregnant

Recent Pregnancy

Allergic to Medications

Heart Condition

Dogs

Tested for Heartworm disease within one year?

Yes

Current on Heartworm preventative? *

Yes

Current on immunizations? (DA2LPPV, Rabies, Upper Respiratory/Bordetella)? *

Yes

Cats

Tested for Feline Leukemia and Feline Immunodeficiency Virus (Feline AIDS)?

Yes

Current on Immunizations (FVRCP-C, Rabies)?

Yes

If vaccines were not done at Animal Care Hospital, please list where we can call to obtain current vaccine records. *

Done at Animal Care Hospital

Done Another Practice (please provide practice name & phone number)Done Another Practice (please provide practice name & phone number)

Surgical and Anesthetic Safety

As with any surgery requiring general anesthesia, there are certain risks that serious complications or even death may result. To minimize the risk of such occurrences, we provide the following additional anesthetic safety procedures.

Today we will be performing a chemistry and CBC blood panel to assure proper organ function, clotting ability, detect anemia or infection, provide a baseline for future reference. We require pre-surgical bloodwork on all of our surgery patients, regardless of age, to maximize safety. If you choose to decline, you indicate that you understand the additional risks involved. *

I AGREE to performing the recommended pre-surgical blood work.

I choose to DECLINE the pre-surgical blood work and I understand the additional risks involved.

Home Again Microchip ID, Permanent identification recognized worldwide. $56 with surgical procedure. Registration Included. *

Yes

Pain medication will be sent home with your pet.

In the event that we are unable to contact you during the procedure, do you authorize us to proceed with extractions or other recommended services during anesthesia? *

Yes

Yes, but not to exceed a total of: $Yes, but not to exceed a total of: $

I am aware of the risks involved with anesthesia and surgery, including possible death or permanent, irreversible injury, and understand the information presented in this surgery form and give Animal Care Hospital permission to proceed with the surgery and to perform any and all life-saving procedure should the need arise. Further, I understand that I am financially responsible for all costs incurred during the surgery, treatment, and hospitalization. *

I understand

Signature *

Clear

Today's Date *

Phone number where you can be reached during and after surgery: *

Do you have texting at this number? *

Yes

Captcha

If you are human, leave this field blank.

Drop-Off Consent Form

Drop Off Consent Form

(To be filled out after scheduling drop-off appointment)

Name

First

Last

Email *

Phone *

Pet's Name

Weight *

Age *

Everything was okay with my pet until

Since then,

My pet is lethargic *

Yes

Water intake has

Decreased

Increased

Unchanged

My pet has not eaten since: *

My pet started vomiting *

Yes

What color?

What substance?

My pet last vomited

My pet has normal stools

Yes

My pet seems constipated

Yes

My pet started having diarrhea

Yes

What color?

What consistency?

Has your pet had access to foods other than recommended pet food?

Yes

My pet has

Lost weight

Gained weight

My pet is

Lame

Sore

Injured

I think his/her _____________ is bothering him/her.

This started

It has

Worsened

Improved some

This has

Never happened

Recently happened

Been a long time (chronic) problem

Please describe in your own words what seems to be the problem

If your pet needs to be sedated for his/her procedure/grooming would you like us to

I give permission for my pet to be sedated if necessary

Call prior to sedationCall prior to sedation

Signature

Clear

If the doctor recommends to run blood work on your pet would you like us to

I give permission for my pet to have blood work done if necessary

Call prior to running blood workCall prior to running blood work

Signature

Clear

If your pet will be spending the night, when does your pet get fed

Both

How much does your pet get fed

When was your pet fed last

Does your pet have any food allergies?

Yes

If yes, to what

I am the owner/ agent for the owner of the animal described above, and I have the authority to execute this consent

Signature *

Clear

Date *

Captcha

If you are human, leave this field blank.

Boarding Consent Form

(To be filled out after scheduling boarding appointment)

PLEASE CALL TO CONFIRM AVAILABILITY BEFORE FILLING OUT THIS FORM. THIS FORM IS TO BE FILLED OUT AFTER SCHEDULING A BOARDING APPOINTMENT.

Please fill out one form for each pet boarding.

Name *

Name

First

Last

Pet's Name *

Boarding from *

Boarding to

Please check the following behaviors that your pet may exhibit

Scared of thunder/lightning

Bites

Climbs fences/Opens cage

In heat

If your dog is anxious due to storms/ separation anxiety we can give them ThunderWunders during their stay as prescribed by the veterinarian. The cost would be $3.00 / per day (for the chew and administration). *

Yes

Feeding: When does your pet eat? PLEASE SELECT ONE: *

BOTH

Cups (per feeding) *

When did your pet eat last today? *

BOTH

NEITHER

Medication

ALL medications must be in original package(s). Medication administered while boarding is $3/day for oral/topical or $6/day for injections.

Medication Name

Dosage

When is it given?

BOTH

Additional instructions (if needed)

Add Remove

Did you give your pets their medications today? *

Yes

What time did you LAST give it? *

time *

I wish for my animal to receive:

Bath (price varies by weight) *

Yes

Nail Trim ($21) *

Yes

Only if needed

Upon discharge, would you like your pet to be sprayed with Cologne?

Yes

"PLEASE READ!!!! Hurricane Season (June 1st-November 30^th)/ Severe Weather Situations:

In the event of any mandatory evacuation (due to a storm or other weather-related issues) or in the event of a tropical storm warning, all owners will be called and asked to be on stand-by. Should a HURRICANE WARNING be posted/ other weather-related issues, all pets are to be picked up within 3 hours of such notice. If the pets are not picked up, they will be transported to a safer location in an air-conditioned van at the owner’s expense.

Please sign to confirm you have read the above *

Clear

I give permission for the following to pick up my pets in the event I cannot:

Emergency Contact Name: *

Emergency Contact Phone # *

As a courtesy reminder, CHECK OUT TIME FOR BOARDING IS 10AM. Any pets departing after 10am will be charged for that day’s boarding. Pets are welcome to stay as late as 6:00PM Monday - Friday and 12:30pm on the 2nd & 4th Saturdays.

I agree to the above terms and conditions *

I agree

Signature *

Clear

Today's Date *

In the event of an emergency please contact me by:

Phone *

Email *

I would prefer to get my pet's pictures sent to me while boarding via

Text

Captcha

If you are human, leave this field blank.

For After-Hours Emergencies, Call Our Office and You'll be Directed to Our Trusted Emergency Referral Hospital.

For After-Hours Emergencies, Call Our Office.

Forms

Pet Information