Crossroads Veterinary Hospital - Surgery Drop-Off Information

Patient's Name

Surgery Drop-Off Information

Do you have any questions or concerns about your pet that you would like the Veterinarian to examine today? How has he/she been doing?

Is your pet currently on any medications?

If he/she is on medications when were they last given? This includes prescriptions, flea/tick/heartworm preventatives, and over-the-counter products and supplements. Are refills needed?

Does he/she have any allergies?

YesNo

Would you like us to perform blood work (pre-op panel $127) prior to surgery?

Ages 8 years and older is required to perform pre-op bloodwork prior to surgery.

YesNo

Initial

Would you like to have a microchip inserted today ($69 fee for placement and enrollment)?

YesNo

Would you like to receive laser therapy after the procedure? ($14 fee applies)

YesNo

Improves blood flow and circulation to tissues involved in surgery and can increase and improve overall healing of the wound.

Please initial

If your pet has fleas upon today’s exam, we will apply a product, at your cost, in order to protect our other patients.

Please ask to see a list or estimate for today’s care if desired.

I am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consent. I hereby consent and authorize Crossroads Veterinary Hospital & MobileVet staff to perform the procedures or treatments. The nature of these procedures has been explained to me, and I understand what will be done.

Printed first and last name:

Sign:

_ Date:

Date

_ Date:

Date

I may be reached at the following number(s) today: