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Surgical Information Sheet

Court Square Animal Hospital
42-34 Crescent Street, Long Island City, NY 11101
Phone: 718-577-4701

Client Name:

Client Address:

Client Phone #:

Client Email:

PET INFORMATION**Ensure Name is As Written on Passport**

Contact Phone:

Primary Contact Person:

Emergency Phone:

Emergency Contact Person:

For each of the following, circle whether he/she needs a refill of their preventative and, if so, specify the quantity (e.g., 1 month, 6 months, etc.):

Heartworm Prevention (Sentinel / Heartgard / for dogs)
For each of the following, circle whether he/she needs a refill of their preventative and, if so, specify the quantity (e.g., 1 month, 6 months, etc.):
A
B
If yes, specify the quantity.
Flea/Tick Prevention (Credelio / Bravecto / Seresto Collar for dogs; Bravecto / Seresto for cats)
Untitled multiple choice field
A
B
If yes, specify the quantity.

Flea/Tick/Heartworm Prevention (Simparica Trio for dogs; Revolution Plus for cats)

Flea/Tick/Heartworm Prevention (Simparica Trio for dogs; Revolution Plus for cats)
A
B
If yes, specify the quantity.

What surgery is the patient here for?

When was the last time the patient ate?

Is the patient on any medication?

Is the patient on any medication?
A
B
List ALL things you are aware that they have ingested in the last week BESIDES the patient’s own food (including but not limited to supplements, human medications, over-the-counter medications, etc.)

Preanesthetic blood screening is required to aid us in making sure a patient’s procedure is as safe as possible. This is critical for all patients, not just older pets. If this has not been performed prior to the day of this procedure, I understand that a Preanesthetic Profile will be taken, which will incur additional costs.

Signature

I fully understand the risks associated with the surgical procedure identified above, which include, but are not limited to, the following: low heart rate, low respiratory rate, decreased blood pressure, decreased bodily temperature, hemorrhage, and even death.

Signature

Would you like to have the patient microchipped today? Fee: $109.25 (This includes implantation of the microchip and the HomeAgain Pet Recovery Registration)

Would you like to have the patient microchipped today? Fee: $109.25 (This includes implantation of the microchip and the HomeAgain Pet Recovery Registration)
A
B

Many animals tend to get excited or anxious post surgery. This can cause an increase in inflammation and delay the healing process. If you think you will have trouble keeping your pet calm, our veterinarian can prescribe medications to help keep your pet calm. The fee for this prescription ranges from $22-30. I give consent to the veterinarian to prescribe calming medications.

Many animals tend to get excited or anxious post surgery. This can cause an increase in inflammation and delay the healing process. If you think you will have trouble keeping your pet calm, our veterinarian can prescribe medications to help keep your pet calm. The fee for this prescription ranges from $22-30. I give consent to the veterinarian to prescribe calming medications.
A
B

I hereby authorize the performance of the surgical procedure identified above. The nature of the procedure has been described to me to my satisfaction. I acknowledge that no guarantee has been made regarding the results of the procedure, nor could any such guarantee be made ethically or professionally. I understand that I assume financial responsibility for all services rendered, and that payment is due upon hospital discharge of the patient.

Signature

CPR

In the event that the patient should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of the patient's status?
By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion. Please select your choice below.
Untitled multiple choice field
A
B

Court Square Animal Hospital takes every precaution to provide the safest sedation and anesthesia for our patients. Even
with extreme care and licensed staff, adverse reactions, which are unpredictable, may occur with any sedation/anesthetic
procedure. These reactions may include, but are not limited to: cardiac arrest, respiratory arrest and/or even death. I, understand there are always potential risks using sedation/anesthesia.

Initial here:
Signature

Signature of Owner or Authorized Agent:

Signature

Date:

I ACKNOWLEDGE THAT NO PERSONAL ITEMS HAVE BEEN LEFT WITH MY PET

Signature