Billings Animal Family Hospital - Boarding Drop-Off Form

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Client
Patient
Age
Date
Procedure(s) to be performed
Phone number(s) where you can be reached TODAY
2
Pet Health History
Yes
Please Select
Yes
No
Is your pet current on vaccinations? We require current Rabies vaccine and Kennel cough (dogs).
Yes
Please Select
Yes
No
Has your pet had any seizures?
Yes
Please Select
Yes
No
Has your pet had ANY illness or injury in the past 7 days (vomit, diarrhea, cough)?
Yes
Please Select
Yes
No
Has your pet been fasted (no food) for at least 10 hours?
3
Is your pet allergic to any medications?
Yes
Please Select
Yes
No
Is your pet allergic to any medications?
If yes, please list
Yes
Please Select
Yes
No
Is your pet taking any medications?
If yes, what and when was the last dose given?
4
Pre-Anesthetic Labwork/Fluid Therapy/Pain Management

Whenever an animal undergoes anesthesia/sedation and surgery, some risk is involved. The amount of risk depends on many factors including age, physical condition and the condition of organ systems (heart, kidney, liver, etc.). Anesthetic risks can be greatly reduced, but not eliminated, with prior knowledge obtained through blood testing. All patients will receive a complete physical exam prior to any anesthesia or sedation, but we also recommend the following testing:
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Basic Testing (CBC, Minimum Chemistry) - Recommended for puppy/kitten to 7 years. ($58.50)
Advanced Testing (CBC, Comprehensive Chemistry) Required for pets over 7 years. ($68.50)
Electrocardiogram (EKG) to screen for heart conditions that can lead to anesthesia complications. ($29.50)
I choose to decline all testing at the time and authorize you to proceed with anesthesia/surgery.
My pet recently had blood testing done on (date)
6
Date
Date
Year
Month
Day
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Intravenous Fluid Therapy (subcutaneous fluids in some patients) will be administered to all patients while under anesthesia to minimize the effects of the anesthetic drugs (low blood pressure, slowed metabolism).

Patients undergoing surgical procedures experience pain. Pain management is not only humane, but allows your pet to heal faster and prevents the potential medical complications associated with uncontrolled pain. We will administer and prescribe pain medication for your pet as deemed necessary.
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Elective Procedures to do today
Nail trim $8.00
Microchip $36.00
Ear Cleaning $15.00
Anal Sac/Glands $18.00
Fecal Testing $24.50
Heartworm test $36.50
Felv testing $ 29.00
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I hereby authorize the Veterinarians and staff of Billings Animal Family Hospital to examine, prescribe for, hospitalize, anesthetize/sedate and/or perform surgery on my pet. I certify that I am the owner or authorized agent for the owner to enter into this agreement. The nature and character of the proposed treatment has been explained to me and I fully acknowledge that no warranty or guarantee has been made to me as to the result or cure. I also understand and accept all of the recognized serious potential risks or complications involved in this treatment, including infection, cardiac arrest or death, as they have been described to me. I assume financial responsibility for ALL serviced rendered, including those deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. I have read and understand this authorization and consent.
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Signed
Clear
11
Date
Date
Year
Month
Day
Should be Empty: