Surgery Admission Form

Animal Care Center of Carters Creek

2690 Spring Meade Blvd, Columbia, TN 38401

Dr. Hemmert ~ Dr. Corley ~ Dr. Taylor

(931) 489-9333

Surgery Admissions Form

Owner's Name: *

Pet's Name: *

Species: *

Dog

Cat

Other

Sex: *

Male

Female

Neutered/Spayed: *

Yes

Age of patient: *

Procedure being performed: *

List any current medications: *

Your pet will have a presurgical exam to identify any medical conditions that could compromise the health of your pet. A physical exam alone may not reveal some underlying health issues and other diagnostics are recommended before placing your pet under anesthesia. These recommendations include bloodwork and an electrocardiogram. While these diagnostics do not guarantee the absence of anesthetic complications, it may identify medical conditions that could require further treatment before anesthesia to reduce anesthetic risks. If abnormalities are found, a doctor will contact you before performing the scheduled procedure.

Please indicate your preanesthetic options below by typing your initials below your selection:

Pre-operative Bloodwork:

Yes, I elect for my pet to receive pre-anesthetic bloodwork at an additional cost of $128.60. REQUIRED FOR PATIENT'S OVER 8 YEARS OLD.

No, I decline the recommended bloodwork and I understand how this could negatively affect the anesthetic risk of my pet.

Electrocardiogram: This is a noninvasive way to identify an abnormal heart arrhythmia prior to anesthesia.

Yes, I elect for my pet to receive a pre-anesthetic electrocardiogram at an additional cost of $85.02.

No, I decline the recommended electrocardiogram and I understand how this could negatively affect the anesthetic risk of my pet.

If your pet is found to have remaining deciduous teeth (baby teeth), these are recommended to be extracted while under sedation. Do you approve to have these removed at an additional cost? NOTE: Extraction of adult teeth is an additional cost based on location and condition of specific teeth. *

Yes. Please extract any deciduous tooth at an additional cost of $25 per tooth (baby teeth only)..

No. Do not extract any deciduous teeth.

Mass Removals: If your pet is having a mass/tissue removed today we recommend that this tissue be submitted for pathology for further analysis. This is a test performed at an off site laboratory and results may take 7-10 days. The cost for this test is $157.30. Please select below if you approve of this service: *

Yes. Please submit this tissue for further analysis.

No. Please dispose of this tissue as deem appropriate.

Would you like for your pet to receive a microchip while under sedation? Microchipping can help identify your pet if they become lost. *

Yes. Please microchip my pet for an additional $69.50

No. I do not want my pet to receive a microchip.

For dental procedures: My pet is undergoing a dental cleaning today and if the doctor determines that one or more teeth need to be extracted, I understand there may be an additional fee. Please initial:

For Ovarianhysterectomies (spays): My pet is receiving an ovarianhysterectomy (spay) today and if she is found to be pregnant or in estrus (in heat), I understand there may be an additional fee ($50-$85). Please initial:

ATTENTION:

If your pet is undergoing an elective procedure, they are required to have current vaccinations that meet our hospital guidelines. It is your responsibility to provide these at the time of admission. If the vaccinations are not found to be current, we will administer required vaccinations at the owner's expense.

If your pet is found to have fleas, ticks, or intestinal parasites at admission, appropriate treatment will be administered at the owner's expense.

ALL PETS BEING SPAYED OR NEUTERED MAY HAVE A SMALL TATTOO PLACED NEAR THE INCISION TO INDICATE THEY HAVE BEEN ALTERED.

I would like to speak to the doctor prior to my pet undergoing procedure _________ YES ________NO *

clear

Date: * +

Emergency Contact Number: *