"*" indicates required fields LinkedInThis field is for validation purposes and should be left unchanged.Client InformationClient Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhonePhonePatient InformationPatientSpeciesBreedColorSex Male Female AgeTODAY'S PROCEDURES AND REQUESTSI hereby authorize the doctors at CAMC to perform the following procedure(s): Spay Neuter Mass Removal Declaw Dental Other Surgery Other Surgery*In addition to the procedure listed above, I would also like to have the following procedures performed for my pet: Express Anal Glands Pedicure Ear Cleaning or Hair Plucked from Ears Microchip Other Other*I would like the following medications refilled today None Refill Refill*I want to pick up the following food for my pet today None Refill Refill*PREVENTIVE CARE STATUSCAMC requires dogs to be current on rabies, distemper, bordetella and heartworm test (for anesthesia) and cats to be current on rabies and distemper to be dropped off at our facility. My pet is current on these vaccinations, and CAMC has the records on file. Please give my pet the following required vaccinations today: Vaccinations Today*HEALTHList any medication your pet has received in the past 24 hours and time given? None List of Medications*MedicationTime Given Add RemoveList any medications your pet takes even if only as needed and last time given (ie: pain meds, allergy meds, ear meds, HG/NG, etc) None List of Medication*MedicationPurposeLast Time Given Add RemoveHas your pet ever had an allergic or negative reaction to a vaccination, medication or food? None List of Allergies*When was the last time your pet ate?Is there anything else you'd like for our doctors and staff to know about your pet? None Notes for our doctors and staff to know about your pet*List any belongings you're leaving with your pet today? None List of Belongings* Add RemoveANESTHETIC RISKShould unexpected life-saving emergency care be required and the hospital staff is unable to reach you, do our doctors and staff have permission to provide such treatment, and do you agree to pay for such service?* Yes No If your pet's heart stops beating, do you want our doctors to try to resuscitate your pet?* Yes No Your pet will be undergoing general anesthesia plus a surgical or dental procedure today. In order to recognize any underlying abnormalities your pet may have, we require your pet to have a pre-surgical blood profile run to determine if there are any additional precautions we need to take before anesthesia and surgery (In some instances, this required blood work has been performed prior to the date of this procedure). If there are problems with the blood work, the doctor will call to discuss the results with you prior to starting the procedure. I understand and agree to this policy if the doctor recommends it.* Yes No I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending doctor or nurse before the procedure is initiated. While I accept that all procedures will be performed to the best of the abilities of the staff at this facility, I understand that veterinary medicine is not an exact science and that no guarantees have been made regarding the outcome of this/these procedures. I am comfortable with the risks involved.* Yes No GENERAL POLICIESYour pet was scheduled as a drop off appointment today. Due to the nature of the procedure(s), at drop off we are not able to specify a specific pick up time. Later in the day, one of our team members will contact you via telephone to let you know when to pick your pet up. If you haven't spoken to us directly or received a message, please make sure you arrive at least 15 minutes before closing time to pick up your pet. Our closing time is Mon-Fri 7 pm and Sat-Sun 5 pm. I understand the pick up time policy Yes No In order to keep you informed about your pet's progress today and to discuss any questions the doctor has about your pet, it is necessary that we be able to reach you by telephone throughout the entire day. If your pet is under anesthesia, and the doctor tries to call to discuss additional recommended procedures and is unable to reach you at the number below, the doctor will not be able to perform those procedures. The doctor will have to wake up your pet from anesthesia, and the recommended procedure will have to be done on another date with another anesthetic procedure. (As an example, after the sedated exam, the doctor may call if your pet is having a dental cleaning to discuss recommended treatments or extractions. If you don't answer the phone, the doctor will not be able to perform the procedures). I understand this policy, agree to be available by telephone and have checked all the phone numbers at the top of this form for accuracy. Yes No I hereby certify that I am the owner of the above-named animal, I am at least 18 years of age, and I have the authority to execute this document. Yes No Doctor performing procedureClient Name* First Last Today's Date* MM slash DD slash YYYY Client Signature*
