Texas Vets for Pets

Client Registration & Anesthesia/Surgery Consent

OFFICE USE ONLY: Cage #: ______________ Date: ______/______/______
In order to expedite the check in process, please fill out this form and bring it with you on the morning of surgery.
Pets Information
Owners Information
Pet Name:
Owner Name:
Breed:
Street Address: (Do Not Use PO Boxes)
Age/Date of Birth:
Sex:
City/State/Zip:
Color:
Phone:
Is your pet microchipped?: Yes
No
Email:
Questionnaire
Yes
No
Has this pet seen a veterinarian?
Is this pet on a heartworm preventive? If yes, indicate the name.
Is this pet on a flea prevention? If yes, indicate the name.
Any medical conditions or concerns at this time? If yes, please describe in the space below.
(Please also check yes or no to the questions on right)
Vomiting
Diarrhea
Coughing
Sneezing
Is this pet eating and drinking normally?
Has this pet ever had a reaction to vaccines or medication?
Has this pet ever had a seizure?
Has this pet ever had a litter? If yes, when?
(Skip if your pet is a male)
How long have you had this pet?
Does this pet spend most of its time indoors or outdoors?
How did you hear about Texas Vets for Pets?
Procedure(s) to be performed:
Please initial the following statements and sign below:
________ Do not allow your pet to eat after 10pm the night before surgery. Water is ok.
________ All pets must be on a leash or in a pet carrier.
________ We will call you with a pick up time when your pet is ready to go home. If you arrive more than 15 minutes after
your assigned pick up time, you may be charged a $25 late fee. If you have prior commitments that will prevent you picking
up your pet at a certain time, it is your responsibility to advise us of this situation when you drop off your pet. Otherwise, we
will assume that you can pick up any time.
________ We make every attempt to accommodate your need for a special pick up time; however, we cannot guarantee your
pet will be ready to go home at that time.
________ Surgeries are NOT done in the order that pets were dropped off. Early arrival does not guarantee early discharge.
Circle One: I
DO
or
DO NOT give consent for photographs of my pet to be used on social media including Texas
Vets for Pets Facebook page.
I certify that I am the legal owner (or duly authorized agent for the owner) of the animal described above, and hereby
authorize and direct Texas Vets for Pets to perform the above described procedure(s) and additional diagnostic and/or
treatment as deemed necessary to promote the health of the above described pet. The nature of the procedure(s) has/have
been explained to me and no guarantee has been made as to the results or outcome. I understand that there are risks
involved. I also understand that pre-anesthetic bloodwork will not be performed by Texas Vets for Pets. I agree to pay, in full,
for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances.
Although I will be paying for the above procedure(s) at the time of check-in, I acknowledge that any additional charges may
apply at the time of release of my pet. Examples of circumstances which might incur an additional charge include, but are
not limited to, application of flea control, hernia repair, pregnancy, in-heat, retained testicles and intervention for a medical
emergency. I understand that other circumstances not listed here my arise which could incur an additional charge.
I have read and understand this authorization. I hereby forever release the doctors and staff of Texas Vets for Pets and any
authorized agents, or representatives from any and all liability for complications arising from the procedure(s).
Owner/Agent Signature: _____________________________________________________________________________ Date: _____________________________
ARE THERE ANY TIME RESTRICTIONS IN YOUR ABILITY TO PICK UP YOUR PET TODAY?:
YES
NO
Please list all phone numbers where you may be reached today: