Morning of Surgery/Procedure Admission Form

Please complete this form the morning of your pet's surgery or procedure, before dropping them off at our clinic. Be sure to click the SUBMIT button at the bottom of the form when you are done.

Your Name*
Your Email Address*
We will email your pet's discharge instructions to this address.
Phone Number where the surgeon can reach you today*
Your Pet's Name*
Your Pet's Procedure Today*
Does your pet live with anyone that has tested positive or been exposed to COVID-19 in the last 10 days, or has a fever, respiratory symptoms, loss of smell or taste, or other contagious illness symptoms?*
If yes, please arrange for someone outside your home to bring your pet in on your behalf, and call us right away if that is not possible, so that we can make a plan together. This is essential so that we can protect our team members and ensure that we can stay open to help pets in need.
When did your pet last eat ANYTHING (including meals, snacks & treats)?*
Did your pet take their full doses of pre-procedure calming medication last night and this morning? What time did they receive each dose?*
Please list all other medications, supplements or treatments that your pet has received during the past 7 days.*
Has your pet had any coughing or sneezing in the past 7 days?*
Has your pet vomited, had diarrhea, indicated pain, or had a seizure within the past 7 days?*
Has your pet had any other symptoms or medical issues arise in the past 7 days?*
Does your pet have a history of licking or chewing at surgery incisions?*
Has your pet had a prior anaesthetic event that went poorly?*
If yes, please provide details.
Do you have any questions for the surgeon this morning?*
If yes, what are they?
Do you understand the cost estimate you have been given for your pet's procedure, and give consent for us to proceed today?*
All surgeries and many procedures (including ultrasounds) require one or more areas of your pet's fur to be shaved in order to prevent infection or perform the procedure. Do you understand and give consent for us to proceed today?*
If you do not answer Yes, we can NOT perform your pet's surgery or procedure.
Can we take pictures of your pet while they are here with us today, to share on social media, our website, etc?
- Yes
- No
Does your pet have insurance?*
If yes, and you do not already have a master insurance claim form on file with us, please provide your insurance company name and policy number so that we can submit your pet's claims for you. If not, but you would like to learn more, leave us a note here and ask the surgery technician at your intake appointment. We can give you information on several reputable companies and arrange a free trial (subject to age limits) to protect your pet while you research and make a decision.
Do you want your pet to receive a microchip today?*
A microchip has a unique identification number that links to your contact information, and can be scanned by any vet clinic or shelter if someone finds your pet. It can help your pet get back home to you if they ever get lost or stolen, escape, or go missing during an emergency like a car accident or fire. The price includes the microchip (about the size of a grain of rice), implantation between your pet's shoulders, and initial registration. This is a one-time cost, and a microchip lasts for your pet's entire life.
- Yes, please give my pet a microchip
- No, my pet already has a microchip
- No thank you
First Name (owner)*
In this and the following questions please enter the Owner Contact Information you would like us to register with your pet's microchip. If your contact information will change soon or changes often, we suggest using a trusted family member's contact information instead. ***If you ever move, change your phone number or change your email you MUST update your pet's microchip information at www.24PetWatch.com or there will be no way to contact you if somebody finds your pet.
Last Name (owner)*
Street Address (owner)*
City (owner)*
Postal Code (owner)*
Home Phone (owner)*
(enter None if not applicable)
Cell/Secondary Phone (owner)*
(enter None if not applicable)
Business Phone (owner)*
Put your extension (if any) in brackets. (enter None if Business Phone is not applicable)
Email Address (owner)*
First Name (emergency contact)*
In this and the following questions, please enter the contact info for an emergency contact in the event you can not be reached. ***Choose an emergency contact who is unlikely to travel with you and whose contact information is unlikely to change over your pet's lifetime. Unfortunately as the years pass some owners forget to update their contact information and we have had lost senior pets brought in, only to discover that all of the phone numbers on their microchip have been reassigned or are out of service. A good guideline is to think of an emergency contact whose phone number will likely NOT have changed if yours has become out of date many years in the future.
Last Name (emergency contact)*
Home Phone (emergency contact)*
(enter None if not applicable)
Cell/Secondary Phone (emergency contact)*
(enter None if not applicable)
Business Phone (emergency contact)*
Put extension (if any) in brackets. (enter None if Business Phone is not applicable)
Do you consent to the release of your name and telephone number to anyone that finds your pet?*
- Yes (Strongly Recommended)
- No, I only want 24PetWatch to communicate with me
Owner Consent*
In order to receive your microchip registration and to be notified if your pet is found, you MUST consent (click Yes) to the consent statement below. Please note that you will receive offers from 24PetWatch for pet insurance and enhanced/phone support subscriptions. These are NOT required, and you can always update your microchip contact information or report your pet lost for free at www.24PetWatch.com. ***Consent Statement*** With your 24PetWatch microchip, we offer you free lost pet services, as well as exclusive offers, promotions and the latest information from 24PetWatch regarding microchip and insurance services. Pethealth Services (USA) Inc., Pethealth Services Inc, PTZ Insurance Services Ltd. and PTZ Insurance Agency Ltd may contact you via commercial electronic messages, automatic telephone dialing systems, pre-recorded/automated messages or text messages at the telephone number provided above, including your mobile number. These calls or emails are not a condition of the purchase of any goods or services. You understand that if you choose not to provide your consent, you will not receive electronic enrollment notification regarding the trial/gift/voucher of insurance and/or free lost pet services which includes being contacted with information in the event that your pet goes missing. You may withdraw your consent at any time.
- Yes, I Consent (Required)
- No, I do not Consent
Is there anything else you would like the surgery team to be aware of this morning?

Morning of Surgery/Procedure Admission Form

Morning of Surgery/Procedure Admission Form

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Morning of Surgery/Procedure Admission Form

Morning of Surgery/Procedure Admission Form

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