URLThis field is for validation purposes and should be left unchanged.Name* First Last Phone*Pet InformationPet Name*Species*Breed*Color*DOB/Age*Weight*Sex* Male Male Neutered Female Female Spayed In-Patient Pet QuestionnaireParvo/DistemperFeline ComboDate of last vaccine RabiesDate of last vaccine BordetellaDate of last vaccine Fecal ExamDate of last exam Heartworm ExamDate of last exam Does your pet show sign of illness today?* Yes No Is your pet currently taking any medications?* Yes No Please list previous surgeriesHas your pet had any previous reactions to anesthesia?* Yes No Any behavior concerns (i.e., biting, timidness, special handling)Treatment AuthorizationPlease check off each statement below I verify I am the owner (or authorized agent for the owner) of the above-named pet.* I verify I am the owner I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that clinic personnel will be employed in the procedure(s) as directed by the veterinarian. High Prairie Veterinary Service (HPVS) will use all reasonable precautions against injury, death, or escape of my pet.* I authorize the use of anesthesia and other medication I accept the risk inherent in any anesthesia or surgery and release HPVS of any liability associated with the procedure.* I accept the risk I further understand that there may be additional, deemed necessary, treatment or expenses upon further examination and commencement of my pet’s treatment plan. If my pet has fleas, ticks, mites, or internal parasites, I understand that I will be charged with the cost of removing them.* I understand Signature of Owner
