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Surgery Form

Save time at your next appointment! Please complete your required Surgery Form online from any device at any time before your visit.

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Surgery Form

Please complete this form completely and accurately so that we can get to know you and your pet(s) before your visit. If this is an emergency or your pet requires immediate attention, please call us at 817-460-4441 for a faster response.

Owner’s First Name: *

First

Last

Email Address *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pet's Name *

Breed *

Age: *

Months or Years

Sex *

Male
Female

Procedure *

Pre-anesthetic Blood Testing

Just as with humans, blood work is performed on any pet undergoing an anesthetic procedure. This blood work gives us an insight on how your pet’s kidney and liver function are as well as other potential concerns such as infections or anemia. Blood work done within the last 3 months is acceptable for today’s procedure.

*Please call our office for the current price of the pre-anesthetic blood work

Microchipping

Microchipping provides a safe, simple and permanent form of pet identification designed to quickly identify lost pets and reunite them with their owners. While your pet is under anesthesia, we can implant the microchip giving you peace of mind knowing your pet has a better chance of being returned home should he/she ever get lost. Anesthesia is NOT required for microchipping. Should you decide to do this later, it can be done as a regular office visit without anesthesia. *We take care of all the paperwork for you!*

*Please call our office for the current price of a microchip for your pet.

Would you like your pet to have a microchip implanted today ? *

Yes I want my pet to get a microchip.
No I do not want my pet to get a microchip.
My pet already has a microchip.

Pet’s First and Last Name: *

I have been advised as the nature of the procedure(s) and the risks involved. I understand that complications including but not limited to infections, cardiac arrest and death could result. I acknowledge that no guarantee has been made as to the result or care.

Please also know that while we take great care in reducing the spread of infections, should your pet not be current on his/her vaccinations we will not be held responsible for any illnesses contracted related to vaccines while they are in our facility. *

I hereby authorize Dr. Karen Smirmaul and/or her designated associates to perform the above-mentioned procedure(s).
I assume full financial responsibility for this animal and agree to pay in full at time of release unless other financial arrangements have been made prior to these procedures.

***Please be sure that ALL questions have been checked before signing. Unchecked areas will prohibit us from performing any procedures on your pet today.

Owner or Authorized Agent’s Signature *

Clear Signature

Daytime Phone Number *

Date *

Printed Name of Owner or Authorized Agent *

Message

Surgery Form

Surgery Form

Pre-anesthetic Blood Testing

Microchipping

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Location

Contact Information

Working Hours

Pet Emergency Clinics in TX

Airport Freeway Animal Emergency Clinic

Animal Emergency Hospital Of North Texas

Animal Emergency Hospital Of Mansfield

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