SURGERY CHECK-IN SHEET
Park Plaza Animal Clinic
Procedure requested: _________________________________________ Date: __________
PHONE NUMBER WHERE YOU CAN BE REACHED TODAY: ____________________________________
Client Name: ________________________ Patient Name: ________________
If my animal has fleas, I understand that it will be treated at a cost of $10.30. ________(INITIAL)
Routine items:
Has my animal eaten this morning? (Even if it was a small amount) YES_____NO______
Would you like an E-Collar for your pet after surgery? ($13-$26) YES_______NO_____
(I understand that the Doctor may require an E-Collar as needed for protection of the surgery site.)
Has your pet ever had seizures? YES_______NO_____
Would you like to update your pet’s vaccines up to date during the surgery? YES_____NO_____
Please complete the blood work you recommend prior to putting my pet under anesthesia and contact me at the number above if any abnormalities are found ($59 or $119 depending on the age of the animal) YES_____NO_____
Please do a heartworm test with the surgery at a discount ($19 vs $30) YES______NO_____
Please give my pet medication for pain management after the surgery ($30 to $70 depending on size of animal). YES_____NO_____
I would like to have the “Home Again” microchip installed during the surgery ($49) YES_____NO_____
Please do a toe nail trim on my pet while under anesthesia at a discount for only $6.90 (regular price $13 to $22 depending on the type of animal) YES_____NO_____
Please ADD a dental cleaning (in addition to today’s non-dental surgery) for additional cost. Please have the doctor examine my pets teeth and call me with an estimate. YES_____NO_____
Please do anal gland expression under anesthesia for ½ price: Regular - $27, Today - $14 YES_____NO_____
If we discover a growth or tumor that needs to be removed, I want the doctor to remove it at additional cost. Please have the doctor call me with an estimate. YES_____NO_____
If there are loose teeth discovered or retained baby teeth interfering with his adult teeth, I want the doctor to remove them while my pet is still under anesthesia (~$15 each) YES_____NO_____
If his ears are dirty and clogged, I want them cleaned and flushed while under anesthesia for only $15 per ear. YES_____NO_____
*(If you have declined bloodwork on an older pet) I have declined pre-anesthetic bloodwork for my pet over 8 years old and understand the risks (see page 2):
_______________________________
Signature of owner
Authorized signature: ___________________________________________________
Date: ____________