Name* Pet Name* Email* Phone*What type of animal will be staying with us?* Canine Feline To the best of your knowledge, is your pet up to date on his/her shots?* Rabies (Canine/Feline) * Bordetella (Canine) * DHLP-PV (Canine) * Influenza Combo (Canine) * FVC-CP (Feline) * FELV (Feline) FIV (Feline) Like you, our greatest concern is the well-being of your pet. Before putting your pet under anesthesia, we will perform a physical examination. However, many conditions including disorders of the liver, kidneys, or blood are not detected unless blood testing is performed. A Blood panel or presurgical screen will be run unless one was completed within the last 3 months. Please read below:My pet has had bloodwork in the last three months* Yes No PRE-SURGICAL SCREEN – Required on ages 0-1.9 years. This will test BUN, which is a kidney function test and a pack cell volume (PCV), which tests for anemia.* Yes, I Agree My pet is over 2 years of age Cost is $30.00SENIOR PANEL – Required on ages of 2 years and older. The senior panel is the most complete test that checks all organ systems.* Yes, I Agree My pet is less than a year old Cost is $78.00Antibiotics: are for spays, neuters, declaws, and ear crops.* Yes, I Agree My pet is not getting spayed, neutered, declawed or ear cropping. Cost is $10.00 - $35.00Antibiotics are required on ALL Dentals. This is for the health of your animal.* Yes, I Agree My procedure does not include a dental In heat or pregnant females will obtain an additional charge of $40.00.* Yes, I Agree My dog is not in heat or pregnant OptionsIV CATH SETUP: this is the setup used for IV FLUIDS | IV FLUIDS: medicated through an IV makes it easier on your pet* Yes, I Agree No, I Decline Cost is $29 for IV Cath Setup, plus an additional $23.00 - $30.00 for IV FluidsCERENIA: Used to prevent vomiting, appetite stimulation post-surgery* Yes, I Agree No, I Decline Cost is $28.00 - $35.00SURGICAL MONITOR: Required on any pet that has a pre-existing condition. - Recommended for 7 years and older. Tracks the heart rate, oxygen level, and any abnormalities during surgery* Yes, I Agree No, I Decline Cost is $29.00We recommend an E-Collar so that your dog will not chew out stitches* Yes, I Agree No, I Decline No, I will bring my own (No Refunds or Returns)Pain ManagementFeline: Pain medications for felines last 72 hours.* Yes, I Agree No, I Decline Cost is $16.50Canine: Vetprofen pills are given before and after surgery for canines.* Yes, I Agree No, I Decline Cost is $9.00 - $29.00I understand that during the performance of the procedures or operations, unforeseen conditions may be revealed that necessitate an extension of the procedure or operation or different procedures or operations than those set-forth above. Therefore, I consent to authorize the performance of such procedure or operations as are necessary and desirable in the exercise of the veterinarian’s professional judgement. I also authorize the use of appropriate anesthetics and other medications and I understand the hospital procedures or operations and the risks involved. I realize that results cannot be guaranteed. I am the owner of the described animal above and have the authority to execute this consent. I hereby consent and authorizes the performance of the procedures or operations listed above. Surgery Requirements 1. All animals must be current on all required vaccinations listed above. 2. All animals must be free of external parasites (i.e. ticks, fleas, etc.) or they will be treated at owner’s expense. 3. Williams-Sebby Veterinary Clinic has my permission to do whatever necessary should an emergency arise. 4. Towels or personal items left at your own risk. When items become soiled it is unsanitary for us to keep without washing them. We may no longer be able to tell your items from ours.Signature required at time of drop off* First Last CAPTCHANameThis field is for validation purposes and should be left unchanged.