Owner Name *

First

Last

Pet Owner DOB *

We may send home controlled substances for your pet’s pain, the state of Indiana requires pet owner date of birth.

Owner Email *

Pet Name *

Phone Number Where We Can Reach You During Surgery: (copy) *

Please enter a valid phone number.

I give permission for my pet to have the following procedure(s) done: *

If you selected other in the question above, please clarify: *

If Dental was selected above; I give my permission for my pet to have the following procedure(s) done: *

I authorize all necessary dental services and procedures.
I prefer to be contacted prior to any additional services/procedures. If I am unavailable, I authorize all necessary dental services/procedures.
I decline any additional services/procedures.

If your pet is on antibiotics, when was last one given? *

Does your pet have any history of seizure activity? *

Yes
No

Is your pet on any Supplements or Medications? *

Yes
No

If yes, please list them below *

Would you like your pet microchipped today? *

Yes
No
Already has one

If you selected to have a microchip for your pet, please fill out the information below. This will be the information submitted to register your pet's microchip

Name

First

Last

Phone

Please enter a valid phone number.

Address

Address Line 1

Address Line 2

City

State

Zip Code

You may add up to four additional phone numbers for your microchip account.

Has your pet been recently treated for fleas? *

Yes
No

If you answered yes to the question above, what flea product was administered and when? *

Our greatest concern is the well-being of your pet. If not already completed, and it's necessary on the day of the procedure, before placing your pet under anesthesia, we will perform pre-operative bloodwork and diagnostic tests to determine if your pet has any special needs and is healthy enough for anesthesia. Our laboratory is fully equipped and staffed to perform these crucial tests and the results will be immediately available to review beforehand. *

Type "I understand" in the box above

Required *

I agree to assume financial responsibility for all services rendered.

Consent: The undersigned hereby warrants that he/she is the owner or authorized agent for the owner of the above-named animal and does hereby request, consent and authorize St. John Animal Clinic to care for, treat or perform the procedures listed above.In emergency circumstances, staff members are authorized to provide emergency care as deemed necessary until further advised by the undersigned owner or agent in person, by phone or in writing.The undersigned further acknowledges that no guarantees have been made except reasonable precautions against complications, injury, escape, illness or death with the understanding that the undersigned will remain fully responsible for all costs of all services provided by St. John Animal Clinic. This clinic is not staffed 24 hours a day. The doctor may recommend the pet be transferred to an emergency clinic if 24 hour medical care is necessary.Payment Policy: We accept cash, checks (with id), Master Card, Visa, Discover and Scratch Pay for payment of services. Payment in full is required at time of discharge. (Type out "I consent" in the box below) *

Signature

Clear Signature

*Please allow 15-20 minutes for surgery admission time.

Surgery Consent Form