Owner Name(Required) First Last Patient Name(Required) Species(Required) Dog Cat Breed(Required) Sex(Required) (Select one)(Required) Neutered /Spayed Intact age(Required)012345678910111213141516171819202122232425Surgery Being Performed Today(Required)SpayNeuterExploratoryMass RemovalMultiple Mass RemovalsDeclawOrthopedic SurgeryLaceration RepairOther Soft Tissue SurgeryOther testingAdditional Information(Required)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?(Required)When did your pet last eat?(Required) Last night This Morning Any known allergies or reactions to vaccines or medications?(Required) Yes No Briefly ExplainDo you want a microchip ($50)?(Required) Yes No Would you like your pet to receive a nail trim under anesthesia ($6)?(Required) Yes No Best contact person and number(s) for today:(Required)Preferred pick up time:(Required) Waiting outside Pickup time Are there any other concerns or questions you may have?(Required) Yes No If 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.(Required) CPR DNR (do not resuscitate) Payment Method(Required) Cash Check Credit Card Care Credit Signature(Required)EmailThis field is for validation purposes and should be left unchanged.