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Home
Our Hospital
Our Doctors
Forms
AAHA Accredited
Hospital Tour
Careers
Services
Wellness Exams
Dental Care
Vaccinations
Microchipping
Spay & Neuter
Senior and Geriatric Wellness
Surgery
In-House Laboratory
End of Life Care
Happy Visit Mondays
View All Services
New Clients
Payment Options
News
Donate to Paisley Paws
Download Our App
COVID-19
Shop Online
Contact Us
Make An Appointment
920-725-8307
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Pre-Surgical Check-In Form
Pre-Surgical Check-In Form
CLIENT INFORMATION
Client Name
(Required)
Pet Name
(Required)
Daytime Contact #
(Required)
Email
(Required)
SURGICAL INFORMATION
Surgery Date
(Required)
Attending DVM (if known)
DO NOT
offer food after 10 pm the night before the procedure. NO breakfast. Water is okay.
Please drop off your pet between
7am and 7:45AM
the day of his/her procedure. If you have a Dental scheduled, please drop off between
7am and 7:30am.
A Doctor or Technician will be contacting you via your above daytime contact number after the procedure is complete (usually by the afternoon) to discuss findings, and schedule a discharge/pick up time for later in the day. Our technicians will go over the discharge instructions with you at the time of pickup.
Please be available by phone throughout the day.
Payment is due at time of service.
This will be collected either over the phone prior to pick up or at the scheduled discharge time.
Is your pet currently taking medications? IF yes, please list the name, concentration and dose.
(Ex: Tramadol; 50mg; Give 1 Tab every 12 hours)
If your pet is on a daily medication that must be given with food, or recommended to be given with food, please ask your veterinary team for guidance prior to administering medications the morning of surgery. If your pet takes a daily medication that does not require, nor is recommended to be given with food, please administer the medication(s) the morning of surgery, as previously recommended by your Veterinarian.
Procedure(s) scheduled: (Choose all that apply)
(Required)
Dental cleaning
Neuter/Spay
Mass Removal
Sedated Ultrasound
Sedated Groom
Other
If Other or Unknown (please list)
If a Dental is scheduled,
the DVMs at APC will
only
extract teeth that are diseased and need removal.
ESTIMATE INFORMATION
Do you have a current estimate for the procedure? (Choose One)
(Required)
YES
NO
If YES, do you have any questions regarding the estimate? (Please list)
If NO, do you want an estimate? (Choose One)
YES
NO
ADDITIONAL SERVICES
Unless otherwise stated on your estimate or by your DVM, most routine surgical procedures
DO NOT
include the following.
Please let us know if you would like the additional services.
Pre-anesthetic blood screening with blood collection fee. (In house- $145, send out $96, blood collection fee $12). Send-out lab work must be done three days prior to the day of surgery. *Starting in April of 2022 mandatory for all patients*(Required)
(Required)
Anesthesia medications are metabolized through the kidneys and liver. This test evaluates kidney and liver health and assesses blood sugar and protein levels to help ensure that your pet is safe under anesthesia. Required for ages 7+.
YES
NO
Microchip ($74)
(Required)
Includes microchip, placement, and enrollment by our staff for lifelong identification.
YES
NO
Hip X-Ray: Diagnostic only (2 view Xray)- $195
(Required)
If recommended by your veterinarian, a radiograph of your puppy’s hips can be taken while under anesthesia to check for evidence of hip dysplasia. Hip dysplasia can lead to osteoarthritis and pain as pets age. Certain large breeds are predisposed to this condition.
YES
NO
Hip X-Ray: Orthopedic Foundation of America (OFA films)- $215
(Required)
A radiograph of your puppy’s hips can be taken while under anesthesia to check for evidence of hip dysplasia. Hip dysplasia can lead to osteoarthritis and pain as pets age. Certain large breeds are predisposed to this condition.
YES
NO
Fecal ($46)
(Required)
A yearly routine fecal flotation is recommended for all pets to check for intestinal parasites.
YES
NO
Resuscitation in the event of a cardiopulmonary arrest. I hereby authorize the DVMs at APC to begin CPR.
(Required)
Although uncommon, respiratory, and cardiac arrest are a risk for any pet that undergoes anesthesia. While we are attempting to contact you at the number you left, resuscitation efforts need to begin immediately. Should your pet have critical needs during the procedure please list if you authorize the staff at Appanasha Pet Clinic to take every able action to prevent/reduce risk of death and incur the costs that may result.
Yes, I authorize CPR and the cost that may accrue.
No, Do NOT resuscitate
Sedation Medication (cost based on weight and medication prescribed)
Sedation medication can help decrease your pet's activity to ensure appropriate healing during the 10-14 day post-op period.
(Required)
Yes
No
E-Collar/ Post Surgical Attire:
E-Collars and post surgical attire can help prevent pet’s from licking or pawing at their incision sites.
ECollar?
Yes
No
Other Post Surgical Attire?
Yes
No
CONSENT/DROP OFF INFORMATION
I understand that with any surgical or anesthetic procedure there is an element of risk, and complications may arise which cannot be predicted. I understand Appanasha Pet Clinic will do everything in the best interest of my pet and his/her safety. If unforeseen conditions arise, which call for necessary procedures or treatments other than the previously authorized services, I authorize such procedures or treatments if reasonable efforts to contact me for consent are unsuccessful.
I certify that I am the owner/agent of the pet listed and hereby authorize the doctors of Appanasha Pet Clinic to perform the above treatment or surgical procedure. I consent to the administration of sedative and anesthetic agents as deemed appropriate by the veterinarian. The doctor explained the nature and purpose of this surgery/procedure to me. Any further questions or concerns should be addressed prior to drop-off.
Client Signature
(Required)
Wondering what to expect on your pet’s surgery day? Follow
this link
to learn more
Full payment due at the time of service, To learn more about Care Credit as a payment option, follow the link to their site
here
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