St. Louis Veterinary Center
SURGERY ADMITTANCE
TO BE COMPLETED BY STAFF: Program_________________________ Copay $_________ Eligibility____________________ Initials__________
PET OWNER:
Name: __________________________________________________________________________Date:_______________________
Last
First
Address: ___________________________________________________________________________________________________
City: ______________________________________________State:___________________________Zip:_____________________
Cell Phone: (________) _________-_____________
Home Phone: (________) _________-______________
Work Phone: (________) _________-______________
Preferred Method(s) of Contact:
E-mail:____________________________________________________
□ Home
□ Work
□ Cell
□ E-mail
PATIENT(S):
Pet’s Name
Cat/Dog
Sex
Age
Breed
Color
1
2
3
4
5
When is the last time your pet(s) has eaten? ________________________________________________________________________
Is there any medical information we need to be aware of? _____________________________________________________________
___________________________________________________________________________________________________________
□
□
Does your pet(s) have any internal/external parasites that you are aware of? (Fleas/ticks/worms/etc.)
Yes
No
If yes, describe: ______________________________________________________________________________________________
In order to control the spread of fleas and diseases they may carry, every pet seen with live fleas will be given a $5 (per pet) flea pill at
the pet owners expense. This is for the protection of all of our patients, clients and staff.
I understand and accept this mandatory treatment in the event that fleas are found on my pet(s) ______Initial
In order to control the spread of ticks and diseases they may carry, we would appreciate any clients willing to purchase a month
long $20 (per pet) flea/tick treatment for their pet(s). This is for the protection of all or our patients, clients and staff.
I understand and accept this optional treatment in the event that ticks are found on my pet(s) ______Initial
SURGICAL PROCEDURES:
Procedure(s) to be performed: (Spay/Neuter, Declaw, Dentistry, Etc.) _______________________________________________
Female(s) - Spay(s): In the event of an abnormality during the procedure (infection, pregnancy, other uterin or mammary
abnormalities, etc.) additional fees will apply. The maximum fee, due at the time of services is:
TO BE COMPLETED BY STAFF: $________ STAFF MEMBER MUST COMPLETE BEFORE YOU INITIAL BELOW
I understand and accept this mandatory fee in the event that an abnormality occurs during my pet(s) surgery ______Initial
Male(s) - Neuter(s): In the event of a retained testicle, the retained testicle(s) may be removed at an additional fee. The fee ranges
from $75-$150 (per retained testicle) depending on the complexity of the procedure.
I understand and accept this optional surgery and the associated fees in the event that my pet(s) is discovered to have a retained
testicle(s) ______Initial
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PAIN RELIEF:
□Accept □ Decline
DOG ONLY: 5 days, chewable take home medication $15.00 □ Accept □ Decline
DOGS AND CATS: Post-surgical pain injection $15.00
I understand and accept these indicated optional treatments and the associated fees. ______Initial
VACCINATION INFORMATION:
□ Yes □ No If no, are you interested in up-dating today? □ Yes □ No
Vaccines to be administered: DOGS: □ Rabies
□ DH(L)PP
□ Bordetella □ Other__________________________
CATS: □ Rabies
□ FVRCP
□ Leukemia □ Other__________________________
Is your pet current on vaccinations?
TO BE COMPLETED BY STAFF: $________ indicated vaccination(s) price, PER PET
Vaccination Declination: “I understand that state law requires rabies vaccination for all pets. I also understand this clinic recommends
Distemper/Parvo vaccination for dogs and/or Feline Distemper vaccine for cats be current. I decline vaccinations at this time. If my
animal(s) bites another animal or person while at this veterinary clinic, I am prepared to show proof of current rabies vaccination. I
understand that if I am unable to provide proof, my animal(s) may have to be quarantined for 10 days with incident and be reported to
my local animal control facility.”
_______Initial
ELECTIVE PROCEDURES TO BE COMPLETED AT THE TIME OF SURGERY:
TO BE COMPLETED BY STAFF: Any unspecified pricing below STAFF MEMBER MUST COMPLETE BEFORE YOU INITIAL BELOW
□ Examination $39.00
□ Microchip $________
□ Nail Trim $5.00
□ Ear Clean $5.00
□ Canine Heartworm Test $________
□ Feline FIV/Leuk Test $________□ Fecal Test $21.50 □ Ear Mite Test $15.50
□ Other:___________________________________________________________________________________________________
I understand and accept these indicated optional treatments and the associated fees. ______Initial
PREANESTHETIC BLOOD SCREENING:
□ Accept □ Decline
$40.00 □ Accept □ Decline
Prep Profile: to check liver and kidneys, strongly recommended for pets over the age of seven years $ 45.00
Blood Coagulation Panel: to test speed of clotting blood before bleeding complications can arise
I understand and accept these indicated optional blood screening panels and the associated fees. ______Initial
I understand that I assume all responsibility for additional risks/complications resulting from refusal of this service. St. Louis Veterinary
Center is to use all reasonable precaution against injury, escape, or death of my pet. I understand that anesthesia and surgeries always
involves some risk to my pet and agree to hold you harmless, in the absence of negligence, in connection with these procedures. I
acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. Additionally, this clinic
and any associated organization (including, but not-limited to BARC, Operation Spot, 909 Vets, etc.) are not responsible for any
complications resulting from pre-existing conditions, or improper inoculation/vaccination, or care of my animal(s) that may have
occurred prior to its submission to the program. In the event complications arise and I cannot be immediately contacted at the above
listed phone number, you are directed to make the decision you deem best for my pet. I hereby certify that I have read and fully
understand the above authorization.
Signature:________________________________________________________________________Date:_______________________
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