Surgery Drop-Off Questionnaire

Complete your surgery drop-off questionnaire below.

Today's Date *

Pet's Name *

Owner's Full Name *

First

Last

Phone *

E-mail *

Surgery Type

Surgery Date

List any other procedures or concerns:

Do you want a phone call before any dental extractions?

Yes
No

If this is a Mass Removal - Do you approve sending the mass out for Histopathology?

Yes
No

Has your pet had any food in the last 12 hours:

What medications or supplements are you giving?

Does your pet need to refill or start Heartworm prevention?

ANESTHESIA AND GENERAL RELEASE

I authorize Franktown Animal Clinic to use all reasonable means to care for my pet. I understand that all anesthesia involves some risk to my pet and will not hold Franktown Animal Clinic liable for any issues that may occur. I authorize pain management which may include anti-inflammatory and/or pain medications, acupuncture, as well as therapeutic laser treatment. *

I have read this statement and I agree.

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