Please list phone numbers where you may be reached between 10am-4pm.(Required)

Would you like to receive a text message update with a recovery photo of your pet following their procedure? If yes, place an asterisk next to the number(s) above to receive the text.(Required)

Yes

**Please respond to the text message so we know that you received it.*

List any medications that your pet is currently taking(Required)

Time that medications were last given(Required)

What time was your pet's last meal?(Required)

Procedure to be performed(Required)

Do you have a doctor preference?(Required)

Yes

Please specify(Required)

Please check the procedures that you authorize us to do prior/during surgery: NOTE: costs vary based on procedures required. Please inquire at drop off.(Required)

Pre-op bloodwork (This will be required for all patients 8 years and older)

Laser Surgery

Vaccinations

Extraction of diseased teeth

Other

Please specify(Required)

If we are unable to reach you, are we able to extract teeth if medically necessary?(Required)

Yes

Please check the items that apply to your pet’s health history:

Does your pet have seizures?

Does your pet have a heart condition?

Does your pet have diabetes?

Has your pet had any significant illness in the past 30 days?

Are there any medications your pet could not tolerate in the past or has an allergy/sensitivity to?

What time was insulin last given and how many units did you give?(Required)

What significant illness has your pet had in the last 30 days?(Required)

What medications can your pet not tolerate or have a sensitivity to?(Required)

For Dental procedures: The Doctor will determine which teeth need to be extracted and/or if oral radiographs are necessary, unless otherwise instructed by owner.

NOTE: Additional fees may apply

During surgery your pet will receive a pain relief injection, which will last 6-8 hours. Post-op pain medication is recommended for all procedures, unless otherwise instructed. Pain medication will be sent home with your pet if the Veterinarian feels that it is warranted.

Owner Release: Ft. Thomas Animal Hospital will use all reasonable precautions for the well being of your pet. I understand that anesthesia involves some risk to my pet. FTAH will not be held responsible or liable in any manner in connection therewith. I assume all responsibility.

NOTE: Full Payment is expected at the time of pick up.

Owner Signature(Required)

Date(Required)

Advanced Directive Form

To allow for optimal treatment, all hospitalized Patients are assigned a CPR code which enables us to carry out your wishes if it should become necessary during or following an emergency or surgical procedure. In the event that my pet arrests (stops breathing or their heart stops) while at Fort Thomas Animal Hospital, I authorize the following level of CPR (please initial your choice):

Do Not Resuscitate (or DNR)

I understand that if my pet stops breathing and/or his/her heart stops beating, Fort Thomas Animal Hospital will not attempt resuscitation or any further life saving measures.

Normal CPR – involving chest compressions, oxygen therapy and medications such as epinephrine, atropine, etc

Having requested such emergency procedures, I agree to be held responsible for a minimum resuscitation fee of $200.00 to pay for the services performed while staff members pursue treatment and try to reach me for further directions. I agree to pay this fee in addition to fees already incurred or for other non-emergency services that may be performed in the event that my pet survives. I also agree that if the Fort Thomas Animal Hospital staff is unable to reach me within 15 minutes after the initiation of CPR procedures, and after a veterinarian determines that further resuscitation efforts are not warranted, CPR procedures will cease.

Patient's Name(Required)

Owner's Name(Required)

First Last

Owner Signature(Required)

Date(Required)

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Surgery Drop-Off Form

Advanced Directive Form

Expert Veterinary Care in Fort Thomas, KY