Owner's Name *

First

Last

Second Contact (Authorized for pet’s healthcare decisions)

First

Last

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

Purpose of Visit *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

County *

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

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 cat indoor only or indoor and outdoors? *

Indoor only
Indoor and Outdoors
Indoor and Outdoors (outdoors only with supervision)

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 was selected, please explain who has been caring for your pet and/or 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. *

Animal Works Veterinary Surgery requires pre-surgical bloodwork for all pets 5 years of age or older. Our pre-surgical bloodwork 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. *

Pre-surgical bloodwork (0-4 Years, always recommended but optional) $120
Pre-surgical bloodwork (5 + Years, required) $120
I decline pre-surgical bloodwork for my pet that is under 5 years of age
My pet has recently had pre-surgical bloodwork performed at Animal Works or another clinic within the last 6 months

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

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

Animal Works Veterinary Surgery requires all pets to be up to date on the Rabies vaccine; dogs will need to be current on the Distemper (DA2PP) Combo and cats on FVRCP vaccines. Please provide proof of vaccinations before or at your appointment. These records must be from a qualified veterinarian. If vaccines are needed, your pet may receive them on the day of surgery, and additional fees will be applied. I understand if vaccines are given, this authorization will be valid for multiple vaccination booster visits for my pet up to 1 year from the date of signature.

My pet will need to be vaccinated on the day of surgery
My pet is up to date on vaccines and I will upload records or bring in at my appointment
My pet is up to date on vaccines, please contact my primary vet clinic for records (list clinic below)

Clinic Name *

Clinic Phone *

Please upload current vaccinations

Click or drag files to this area to upload. You can upload up to 5 files.

Additional comments or concerns

Date of your pet’s surgery appointment *

Procedure or treatment to be performed: *

Cherry Eye Repair - which eye? *

If other, please specify *

Other services requested while under anesthesia

If other, please specify *

After any surgery, it is possible your pet will want to lick or chew at the surgery site. Therefore, we include an e-collar with this surgery. We also have surgical suits available for $35 plus tax. *

I accept a surgical suit for my pet
I decline a surgical suit and will just receive the e-collar

I certify that I am, in fact, 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 and authorization for the above procedure to be performed. 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. The nature of the operation or procedure(s) has been explained to me, and I understand what will be done. I understand that unforeseen conditions may be revealed that necessitate an extension or variance in the procedure(s) set forth above for the safety of my pet. I hereby consent to and authorize the performance of such altered and/ or additional procedures as are necessary for the veterinarian’s professional judgment. I accept responsibility for any result in additional fees. I understand Animal Works Veterinary Surgery 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 risks. I fully understand that the prior medical consent (if applicable) I signed for my pet’s pre-surgical consult pertains and is valid during this procedure as well. My initial certifies that I am over 18 years of age. I agree to the use of any photograph(s) or video(s) of me and/ or my pet for educational and promotional purposes 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

Anesthetic/Sedation Risks: 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. These risks have been explained to me, 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 have read and understand

Intravenous Catheter Placement & Fluid administration during surgery/ recovery: I fully understand my pet may receive intravenous (IV) fluids during the procedure to help maintain hydration, normal blood pressure and support the cardiovascular system. If your pet receives IV Fluids, they may have a shaved area on the front of their leg as the hair must be removed to allow the area to be disinfected properly before inserting the catheter; this area will be bandaged and can be taken off once you arrive home. The fee for intravenous catheter placement, catheter maintenance, and intravenous fluid administration during surgery and recovery is included in the procedure unless noted by the staff of Animal Works Veterinary Surgery. *

I have read and understand

I fully understand my pet may receive medications as deemed necessary by the veterinarian. These medications include but are not limited to pain management and antibiotics. I also understand that any medication has the potential to cause adverse reactions that cannot always be predicted. If concerned, I will bring my pet back to Animal Works or to my primary veterinarian to have these reactions addressed. I accept responsibility for any result in additional fees. *

I have read and understand

I fully understand that Animal Works Veterinary Surgery is a surgical center and not a 24-hour hospital. I accept these limitations of service and understand I would need to take my pet to a 24-hour hospital if complications arise after surgery or treatment. On rare occasions, Animal Works Veterinary Surgery may offer to keep my pet overnight. I understand that no staff will be attending to my pet during this time, and I assume the risk. If I, upon my own accord, choose to go to another veterinary hospital or emergency hospital before or after surgery for my pet, I fully understand that Animal Works Veterinary will not be liable for any charges incurred from the treatment that was given at any other veterinary-related facility or hospital. *

I have read and understand

I further agree to make prompt and complete payment for all treatment upon discharge of the above pet. I also understand and agree that in case of non-payment or non-pick up within 24 hours, Animal Works may relinquish my pet to a local rescue or shelter of their choosing. I will be subject to all billing and/ or finance charges associated with my account. Should it become necessary to settle my account through a collection agency or attorney I, the undersigned, agree to pay all costs of collections. *

I have read and understand

I agree that a digitally scanned or photographic copy of this authorization and instruction shall be as valid as the original, even if my digital signature is not complete or legible. *

I have read and understand

Digital Owner / Authorized Agent's Signature *

Date *

Soft Tissue Authorization Form

Please complete this form before your visit.

Got questions?
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