The owner of the pet must be the one dropping off for the procedure. The surgery technician will need to go over the procedure and the procedure estimate. If the owner cannot be present, you will need to come in or call us 24-48 hours before the procedure. We will not be able to continue with the procedure without speaking with the owner.
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Initial
Pet's Name
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First Name
Last Name
Your Name
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First Name
Last Name
Best phone number to reach you on procedure day
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-
Area Code
Phone Number
Alternative Contact Name
First Name
Last Name
Alternative Contact Phone
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Area Code
Phone Number
Date of Procedure
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-
Year
-
Month
Day
Date
Reason for your pet's visit today? Select all that applies
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Spay/Neuter
Dental Cleaning
Mass Removal
Other
Does your pet have any plates, screws and/or pens? If yes, please call the office so we can start them on antibiotics at least 5 days before their procedure.
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Yes, my pet has plates, screws and/or pens
No, my pet does not have plates, screws and/or pens
Unsure
If your pet is having a mass removal, please circle it/them with a sharpie or other permanent marker. If you can not mark them, we will mark or shave them while you are here.
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Initial Above
More than likely you were given an estimate or sometimes more than one estimate for the procedure. Please call our hospital prior to the day of surgery with any questions about your estimate as canceling the surgery the day of will result in a $75 cancelation fee .
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Initial Above
Your pet cannot have any food after midnight/on the day of the procedure.
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Yes, I understand that my pet cannot have food the day of procedure
No, I have question and I will call the office
Unsure
If your pet has been vomiting or having diarrhea, please call the office to see what's best before your pets procedure.
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Yes, my pet has been having an issue and I will call right away
No, my pet isn't having any issues at this time but will call if any issues arise
Unsure
If your pet has been coughing sneezing or breathing hard, please call the office to see what's best before your pets procedure.
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Yes, my pet has been having an issue and I will call right away
No, my pet isn't having any issues at this time but will call if any issues arise
Unsure
Does your pet have any allergies?
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Yes
No
Unsure
If yes, please describe/provide more information
Has your pet ever had any adverse reaction to medication?
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Yes
No
Unsure
If yes, please describe/provide more information
Please list any medications, supplements, topical treatments your pet has received in the past 72 hours and when they were last given: If none have been given please state none.
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Please note: Murrieta Oaks Veterinary Hospital will require that a treatment will be applied at the owner’s expense to any pet with evidence of fleas, flea dirt, or ticks.
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Initial Above
Is Your Pet Current On Vaccinations?
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Yes
No
I Am Not Sure
My pet's vaccines were administered last by:
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At Murrieta Oaks Veterinary Hospital
I Am Not Sure Where
Other
Does Your Pet Have A Microchip?
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Yes
No
I Am Not Sure
Do you want your pet microchipped today? (Additional Fees Apply)
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Yes
No
Does Your Pet Have Known Health Concerns and/or Chronic Disease or Conditions?
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If yes, please tell us more. If no, please note N/A
Is There Anything Else We Should Know About Your Pet?
If yes, please tell us more. If no, please note N/A
Is There Anything Else You Would Like To Discuss Today?
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I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize the above procedure to be performed by Murrieta Oaks Veterinary Hospital. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian.
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Initial
The owner of the pet must be the one dropping off for the procedure. The surgery technician will need to go over the procedure and the procedure estimate. If the owner cannot be present, you will need to come in or call us 24-48 hours before the procedure. We will not be able to continue with the procedure without speaking with the owner.
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Initial
I have been advised as to the nature of this procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any sedation or anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. This risk includes serious bodily injury or death. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. I accept responsibility for any result in additional charges.
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Initial
I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital).
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Initial
In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference:
Please proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred (starting at $500).
Please do not proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred.
Tattooing saves pets from undergoing unnecessary anesthesia and surgery. In the event that they get lost or rehomed and their history is not known. Would you like your pet tattooed while under anesthesia for spay or neuter?(no additional charge for this service)
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Yes
NO
Not having spay or neuter
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Submit
Should be Empty: