Surgery Drop Off Form Owner Name* First Last Patient Name*Species*DogCatBreed*Sex*(Select one)*Neutered /SpayedIntactage*012345678910111213141516171819202122232425Surgery Being Performed Today*SpayNeuterExploratoryMass RemovalMultiple Mass RemovalsDeclawOrthopedic SurgeryLaceration RepairOther Soft Tissue SurgeryOther testingAdditional Information*Our greatest concern is the well-being of your pet. The doctor will perform a physical examination before administering anesthetic agents. Anesthesia does carry some risk, even for a routine surgery. Circle B Veterinary Hospital’s doctors and staff utilize a safe anesthetic protocol unique to each patient. All patients will receive pre-anesthetic bloodwork including coagulation times, IV catheter, IV fluids and post-operative pain medication if indicated.What medications is your pet currently taking and when was the last time it was given? Refills?*When did your pet last eat?*Last nightThis MorningAny known allergies or reactions to vaccines or medications?*YesNoBriefly ExplainDo you want a microchip ($50)?*YesNoWould you like your pet to receive a nail trim under anesthesia ($6)?*YesNoBest contact person and number(s) for today:*Preferred pick up time:*Waiting outsidePickup timeAre there any other concerns or questions you may have?*YesNoIf yes, briefly explainIf there are any complications (if your pet is severely ill or has a life-threatening reaction) please select one if we CANNOT reach you for decision.*CPRDNR (do not resuscitate)Payment Method* Cash Check Credit Card Care CreditSignature*EmailThis field is for validation purposes and should be left unchanged.