Office Visit and Patient Drop-Off Release Form Step 1 of 616% The Small Animal Clinic at CEC Thank you for trusting us with your pet today! The following information will be used by our veterinary team to understand your desires for your pet's visit today.Date* MM slash DD slash YYYY Name* First Last Phone*Pet's Name*Is this an office visit or a patient drop-off?* Office Visit Patient DropWe will need to be able to contact you or someone with permission to make medical and financial decisions:Who will we be speaking with?*Phone Number*Alternate Phone NumberEmail* During surgical procedures, please be available throughout the day for calls.Ideal pick up time: : Hours Minutes AMPM AM/PM(Pick-up times will vary depending on procedure and caseload; We will call when your pet is ready for pick up)Reason for visit (check all that apply):* Preventative Care Comprehensive Exam Dental Prophylaxis Spay or Neuter Weight Management/Nutritional Questions Chronic Disease Monitoring Surgical Procedure Illness Injury OtherOther*Please elaborate on above selection*Do you have any other concerns? (Check all that apply): Eating Drinking Bad Breath Lethargy Weight Loss Weight Gain Itching/Scratching Difficulty Rising Scooting Shaking Head Vomiting Diarrhea Skin Masses/Lesions Urinary Issues Behavioral Problems None OtherOther*Additional Comments/ConcernsWhen did your pet last eat? (Yesterday or Today; AM or PM)*Has your pet ever experienced an adverse reaction to any medication?* Yes NoPlease describe:*Is your pet ever in pain after vaccines or any other procedure?* Yes NoPlease describe:*Is your pet taking any medication(s)? Include any over the counter supplements and medications.* Yes NoPlease describe:*Any refills needed?Any skin care products needed? Shampoo Conditioner Ear Cleaner NoneA flea control product will be administered to any pet that has live fleas. Making your pet more comfortable and protecting the hospital and other pets from a flea infestation. When given an additional charge will be applied. Please initial below.*Additional Services for Your Pet's Care & Safety Microchip: Many pets will become lost at some point in their lifetime. Some are never found but with a microchip, your pet can be identified even if no collar or tag is present. A microchip increases the chances of being reunited with your pet if lost. Doctor discretion with small or young pets. ($56) Nail Trim: Long nails can cause discomfort for the pet and can cause damage to the delicate structures of the feet. Would you like your pet's nails to be trimmed today? Pets who are undergoing an anesthetic procedure will have their nails trimmed at no charge. ($32) Anal Gland Expression: If you have noticed any licking/scooting or chewing, their glands might be blocked and require a manual expression. ($23) Pre-medicate prior to Vaccinations: While the chances of vaccine reactions are low, there is always a risk for your pet to react even if they have had no prior history or symptoms of vaccine reaction (soreness, swelling, vomiting, diarrhea). We may recommend a diphenhydramine injection prior to vaccination to minimize the chance of a reaction. Post-vaccination pain medications are also available. (varies) Heartworm Prevention: Does your pet need a refill on heartworm prevention? We recommend year-round prevention. Heartworm disease is caused by a long slender worm that lives in the heart and adjoining vessels of infected pets. Heartworms are transmitted by mosquitoes and can cause substantial damage to the heart and lung before the pet shows any sign of disease and can also be fatal. Dogs will require a yearly heartworm test preformed prior to prevention being administered. (varies) Flea & Tick Prevention: Does your pet need a refill on flea and/or tick prevention? Fleas and ticks can carry and cause disease and discomfort in humans and animals. Ask about available products for recommendations. (varies)Please indicate if you would like your pet to receive any of the following services, additional charges will apply.* Microchip Nail Trim Anal Gland Expression Pre-medicate prior to vaccinations Heartworm Prevention Flea & Tick Prevention NoneIf your pet is undergoing sedation or anesthesia today, please read and initialPre-anesthetic blood panel: preformed for every patient undergoing general anesthesia to help increase the safety of your pet. Some abnormal results may warrant additional testing and the medical team will contact you. In some instances, abnormal results will result in the procedure needing to be canceled or postponed for your pet's safety. This is included in the estimate for every anesthetic procedure.*InitialPain Medication: Pre- and Post-operative pain medications are given as needed to every anesthetic patient. If determined to be medically necessary, pain medication to go home with your pet may also be recommended. Additional charges may apply.*InitialCritical Intervention: While your pet is under anesthesia, critical intervention may be needed to maintain normal heart rate, blood pressure and oxygen levels. In these situations, client permission is critical for intervention and may not be able to be immediately obtained. By initialing below, you grand permission for treatment if warranted.*InitialAuthorizationI authorize, the doctors and staff of "The Small Animal Clinic at Colorado Equine Clinic" complete authority to perform procedures including anesthesia, surgery, diagnosis, dentistry (including extractions), any additional diagnostic procedure, or treatment to promote the patient's wellbeing, and or help with their medical conditions. I understand that the Doctors and staff will use all expected precautions against injury, escape and death of my pet. I also understand that all sedation/anesthesia involves an innate risk and in rare occurrences death. I release the Doctors, staff, and "The Small Animal Clinic" from any and all liability arising from all treatments, anesthesia, and procedures involving my pet.Media Release: I authorize my pet to be photographed/videoed by CEC staff for educational and promotional purposes. Names will be kept anonymous, but images may be seen in a public environment.* I agree I do not agreeYour signature below certifies that you own the above described animal(s), have authorized The Small Animal Clinic at Colorado Equine Clinic to treat and care for your pet, and agree to provide payment at the time of service.*Type Name*Date MM slash DD slash YYYY By signing, I am consenting as either the owner or legal agent of the owner. EmailThis field is for validation purposes and should be left unchanged.
