Name *

First

Last

Email *

We require all our patients to have a current Rabies vaccination.

Vaccinations: Needed Vaccines *

or UTD *

My pet is not current. Please vaccinate as needed for *

Pre-Anesthetic Bloodwork: We require pre-operative blood screening prior to anesthesia to identify potential existing internal problems that may not be evident on physical examination. The lab work performed will be based on patient’s age and pre-existing conditions. *

Hospitalized Patients: Owner gives us permission to perform necessary diagnostics tests including bloodwork, radiograph, and ultrasound. Hospitalized patients who require IV fluid therapy and medications will receive them at the Doctor’s discretion. *

Authorize microchip implantation: *

Yes
No

Authorize Procedure to be performed: *

Dental Procedures: permission for extractions: *

With Phone Call
Without Phone Call

Is your pet exhibiting any coughing, vomiting, sneezing, diarrhea, excessive thirst, or any other SIGNS OF ILLNESS or CONCERNS you would like addressed during your surgery appointment? *

Is your pet on any medications / being treated for pre-existing conditions? *

Yes
No

If yes, list

Is your pet on HWP/FTP: *

Yes
No

If yes, list products here

Has your pet had anything to eat today *

Yes
No

CONSENT:

I certify that I am the owner/custodian of the above animal and I do hereby consent and authorize the veterinarians of Leach Animal Hospital and its staff to hospitalize my pet and perform procedures and/or treatments deemed necessary for the health and safety of my pet described above. However the doctors and staff will not be liable in any manner for the care, treatment, or safekeeping of my pet. I release Leach Animal Hospital and the staff from any and all liability while my pet is under their supervision. I understand that I am responsible for all the costs associated with the care, treatment, or boarding of my pet and that full payment for any services must be made when my pet is discharged. I further understand that abandonment of my pet does not release me from any financial obligations to Leach Animal Hospital. If my pet is abandoned a written notice will be sent to me. I understand that after 5 days of written notice, my pet will be considered abandoned and that Leach Animal Hospital will dispose of my pet in any manner they deem necessary.

I understand that my pet is being admitted for the following procedure(s): *

Owner/Custodian Signature: *

Date *

Date

Time

Emergency phone number: (1) *

Emergency phone number: (2) *

Surgery Intake Sheet

Leach Animal Hospital