Purpose for Visit

Owner's Name *

First

Last

Second Contact (Authorized for pet’s healthcare decisions)

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

County *

Email *

Primary Phone *

May we text you instructions, updates, etc. at this number? *

Yes
No

Secondary Phone

May we text you instructions, updates, etc. at this number?

Yes
No

Communication Preference *

Email
Phone Call
Text

How did you hear about our hospital? If referred by someone, who should we thank? *

Date of your appointment

Referring Veterinary Hospital

Referring Veterinarian

Pet's Name *

Species *

Dog
Cat

Sex *

Male
Male (neutered)
Female
Female (spayed)

Age/Date of Birth *

Breed *

Color *

Is your pet up to date on vaccinations? *

Yes
No

Vaccines requested at this appointment

Click here for more information on vaccines we offer.

Has your pet ever had a reaction to any vaccinations? *

Yes
No
Unknown or New Pet

Is your pet primarily indoors or outdoors? *

Indoor
Outdoor

Is your pet fearful or aggressive around strangers? *

My pet has been in my care for at least the last two weeks and to the best of my knowledge, my pet is currently healthy, free from any symptoms of illness such as vomiting, diarrhea, coughing, sneezing, lethargy, or loss of appetite. *

Yes
No

If no, please explain what symptoms you are seeing.

Please list any medical conditions, allergens, previous surgeries, or other vital information regarding your pet. If you have nothing to add, please put "none" in this section. *

Please list any medications or supplements that you currently give to your pet. If you have nothing to add, please put "none" in this section. *

Please upload referring veterinarian notes, bloodwork, current vaccine records, and any other vital records

Click or drag files to this area to upload. You can upload up to 10 files.

Additional comments or concerns

Vaccines are important in reducing or preventing many diseases. I understand they are not always 100% effective, especially if my pet was exposed prior to vaccinations given. I will not hold Animal Works Veterinary Surgery or its staff liable for lack of vaccine efficacy. *

I have read and understand

Although intended to prevent disease and illness, any vaccine and/ or medication has the potential to cause adverse reactions that cannot always be predicted. It is important that I keep a close eye on my pet especially for the next 24 hours. I release Animal Works Veterinary Surgery and its staff, whether paid or volunteer, of liability for such complications and/ or cost associated with such complications. If concerned, I will bring my pet back to Animal Works or to my primary veterinarian to have these side effects addressed. Animal Works will assist with treatment as much as possible but will not reimburse me for treatments associated with these side effects. Animal Works does not perform exams prior to vaccinations, we reserve the right to refuse vaccinations if concerned for the well-being of the animal. *

I have read and understand

Animal Works Veterinary Surgery requires a Pre-Anesthetic Profile for all orthopedic surgeries, and all pets 5 years of age or older. Our Pre-Anesthetic Profile checks your pet’s organ functions to see if we need to alter our anesthetic protocol or medications to go home. If your pet has recently had bloodwork performed at another clinic, please upload with other records, in certain situations it may be advised to repeat bloodwork if there was a concern. *

Pre-Anesthetic Profile (0-4 Years, always recommended but optional, required with all orthopedic surgeries) $120
Pre-Anesthetic Profile (5 + Years, required) $120
I decline Pre-Anesthetic Profile for my pet that is under 5 years of age
My pet has recently had bloodwork performed at another clinic within the last 6 months.
I would like to further discuss the option for bloodwork with the doctor.

For sedated palpation or anesthetized radiographs: Although every effort is made to make anesthesia/sedation as safe as possible, there are inherent, unavoidable, assumed risks with any anesthetic procedure and results cannot be guaranteed. I understand the risk involved and I am encouraged to discuss any concerns I have about the risks with the staff at Animal Works Veterinary Surgery before the procedure is performed. *

I authorize the use of appropriate anesthetics and other medications, if deemed necessary
This is a pre-surgical visit only

I certify that I am the owner or the authorized agent for the owner of the animal listed above. I grant the veterinarians and staff of Animal Works Veterinary Surgery my consent to receive and treat the animal named above as they deem necessary. I fully understand that Animal Works veterinarians are Colorado licensed doctors of veterinary medicine but are not veterinary specialists and maintain and continue to give my consent. I am aware that the practice of veterinary medicine is not an exact science and, thus, no reimbursement or guarantees have been made as to results or cure. I understand that there could be unforeseen risks associated with this treatment and that there may be medical or surgical procedures that are not anticipated but necessary for the safety of my pet. I hereby consent to and authorize the performance of such altered and/ or additional procedures as are necessary in the veterinarian’s professional judgement. I accept responsibility for any result in additional fees. I understand Animal Works will use all reasonable precautions against injury, escape or death of the animal but will not be held liable or responsible in any manner and thoroughly understand that I assume all risk. I agree to the use of any photograph(s) or video(s) of me and/ or my pet for educational and promotional purpose of Animal Works Veterinary Surgery (including but not limited to: webpages, newsletters, brochures and displays) I further understand that I will not be paid for the use of such photograph(s) or video(s). My signature certifies that I am over 18 years of age. * *

I have read and understand

Digital Signature *

Medical Treatment Authorization Form

Please complete this form before your visit.

Got questions?
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