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Intake Form
Intake Form
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We look forward to seeing your pet at District Vet. Please fill out the following fields then sign and date the bottom.
First Name
(Required)
Last Name
(Required)
Pet's Name
(Required)
Email
(Required)
Phone Number
(Required)
Select procedure(s):
(Required)
Oral Surgery/ Dental Procedures
Spay (female)
Neuter (male)
Mass removal
Other (please describe)
Can select more than one option
Please describe "Other"
(Required)
Dental
Many pets require sedation before our doctors can complete a thorough dental exam. Each tooth must be carefully evaluated so our veterinarian can choose the best treatment. To help you avoid surprise charges for your pet, a staff member will call you at your request to update your estimate during the procedure if additional services are needed. We recommend completing all needed dental procedures during this visit so you can avoid scheduling another appointment with additional sedation costs.
Note:
if we cannot reach you, our doctors will use their best medical judgment in proceeding when treating your pet. If there are diseased teeth, they may be removed.
Please check one of the options below:
(Required)
Perform necessary procedures and extractions.
Provide only the requested dental cleaning and polishing at this time.
Call me after the sedated dental examination and provide an estimate of any additional procedures.
IT IS IMPERATIVE THAT WE CAN REACH YOU IMMEDIATELY ALL DAY WHILE YOUR PET IS HERE FOR A DENTAL PROCEDURE.
Contact Person on the date of the procedure:
(Required)
Phone
(Required)
Person picking up your pet:
Same
Other
Name
(Required)
Phone Number
(Required)
If your pet does not have a
microchip
, would you like us to place one today?
This is highly recommended in pets here for spay and neuter.
Would you like to add a microchip for your pet?
(Required)
Yes
No
Is your pet on any medications aside from heartworm and flea/tick prevention?
(Required)
Yes
No
Please list the medications your pet is taking and the times they are administered:
(Required)
Will you be giving this medication the day of the procedure?
(Required)
Yes
No
Is there anything else needed on the procedure day, or new issues you’d like the doctor to be aware of?
(Required)
Yes
No
Please list additional comments, questions, or concerns.
(Required)
I understand that my pet may be sedated and/or anesthetized. Although every effort is made to make this procedure as safe as possible for my pet, there are inherent risks with anesthesia and surgery that may include the possibility of death. I am encouraged to discuss any concerns I have about those risks with the veterinarian.
I hereby certify that I have read and fully understand this authorization for treatment. I am the owner or agent for the pet and have the authority to execute this consent. I assume financial responsibility for all charges incurred to the above patient and agree to pay all such charges when the pet is released from the hospital. I understand that in the event of an emergency my pet will have treatment provided at my cost and I will be contacted as soon as possible. I understand that any procedure, especially anesthesia, involves some risks and that results cannot be guaranteed. I will not hold the veterinarian, Hospital or staff responsible in any manner and assume all risks.
(Required)
I agree
In the situation of an adverse event while your pet is hospitalized, every effort will be made to follow your wishes. In all cases we will make every attempt to contact you as soon as possible.
Should CPR be necessary, please check your preference:
(Required)
Basic CPR
Do not resuscitate
After carefully reading the above, I have signed the agreement.
(Required)
Reset signature
Signature locked. Reset to sign again
Print Full Name
(Required)
Date
(Required)
MM slash DD slash YYYY
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.
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1
Call us or schedule an appointment online.
2
Meet with a doctor for an initial exam.
3
Put a plan together for your pet.
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