FacebookThis field is for validation purposes and should be left unchanged.Client Name*Phone*Email* Pet InformationPet Name*Species*Breed*Color*DOB/Age*Weight*Sex* Male Male Neutered Female Female Spayed In-Patient Pet QuestionnaireDoes 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):Belongings left with your pet todayPlease check off all procedures accordingly Bloodwork* Yes No X-Rays* Yes No Administration of any/all medications* Yes No Sedation, if needed for safety of your pet* Yes No IV Catheterization with administration of fluids* Yes No Life saving measures* Yes No Humane euthanasia* Yes No Vaccination HistoryParvo/Distemper ComboFeline ComboRabiesRattlesnakeHeartworm TestFecal FloatTreatment Authorization - Please read and initial each statement below: Payment is due at time of service and this form must be complete. I verify I am the owner (or authorized agent for the owner) of the above-named pet and authorize the above procedure to be performed.* I understand 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 understand I accept the risk inherent in any anesthesia or surgery and release HPVS of any liability associated with the procedure.* I understand 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
