Pre-Surgical Admittance Form – Brockville Animal Hospital

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The Brockville Animal Hospital Team would like your help to evaluate your pet prior to anesthesia. Please complete this online form (below) and submit prior to your pet’s admittance.

(Printable form)
If you require a printable form, please remember to bring this filled out form with you to the hospital for your pet’s admittance.

Date: _______________________________________________________________________________
(Date of Admittance)
Affix labels here:
(Office use only)
Date of Your Pet's Appointment*
Date Format: MM slash DD slash YYYY
OWNER'S INFORMATION:
Name*
First Last
Address*
Street Address Address Line 2 City Province Postal Code
Day-Time Phone*
Evening Phone
Mobile Phone
Email*
Enter Email Confirm Email
CO-OWNER'S NAME AND CONTACT INFO:
Name
First Last
Phone
EMERGENCY CONTACT INFO:
We are required to have an emergency contact on file for your pet. This is the first person we will contact in an emergency involving the well-being of your pet should we be unable to reach you. An emergency contact should be someone who does not live at the primary residence.
Emergency Contact Name*
First Last
Emergency Contact Phone*
PET INFORMATION:
Pet's Name*
Species*
PLEASE ANSWER THE FOLLOWING QUESTIONS:
Coughing?*
- Yes
- No
If Yes, please provide details.
Sneezing?*
- Yes
- No
If Yes, please provide details.
Vomiting?*
- Yes
- No
If Yes, please provide details.
Diarrhea?*
- Yes
- No
If Yes, please provide details.
Seizures?*
- Yes
- No
If Yes, please provide details.
Weakness?*
- Yes
- No
If Yes, please provide details.
Excessive Drinking?*
- Yes
- No
If Yes, please provide details.
Loss of Appetite?*
- Yes
- No
If Yes, please provide details.
Have you noticed any signs of heat?*
- Yes
- No
If Yes, when was the last heat?
When was the last time your pet ate?
You can let us know at time of admittance.
When was the last time your pet drank?
You can let us know at time of admittance.
Please list any medication or supplements your pet is taking and when were they given last?
Does your pet have any known allergies to medications?*
- Yes
- No
If yes, please list.
Has your pet had any known reactions to anesthesia?*
- Yes
- No
If your pet requires any vaccinations would you like us to give them while here?*
- Yes
- No
If not already, would you like us to microchip your pet?*
- Yes
- No
Are there any current or past medical conditions of which we should be aware?*
- Yes
- No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Will you be submitting a pet insurance claim for this surgery?*
- Yes
- No
If yes, who is your pet insurance provider?
As part of the surgery admission process, please let us know if you have pet insurance and if you plan to make a claim. If you don’t have insurance, consider the benefits: it can ease financial stress, cover unexpected costs, and ensure your pet gets the best care possible without delay. If you need more information about pet insurance or have any questions, feel free to reach out to us. We’re here to help!*
- Yes, please provide me with pet insurance information.
- No thank you.
Do you need any flea, tick, or heartworm/intestinal parasite preventatives for your pet?*
- Yes
- No
If yes, please list what you would like us to get ready for you.
Have you downloaded our Brockvillevet App?*
- Yes
- No
If no, please download the Brockvillevet App and active your account to collect loyalty paw reward stamps for your pet's visit. We will add loyalty stamps to your app once payment is received. Please let us know if you have any questions.
Please let us know if you are having any issues downloading and setting up your app account. We are happy to help!
Do you have any other concerns or requests for your pet's stay with us?
PRE-ANESTHETIC BLOOD TESTING:
Our Veterinarians recommend pre-anesthetic blood work before all procedures requiring anesthetic. A full examination is performed, but blood work will give us more insight into your pet’s well being. Many disorders of the liver and kidneys are not detected unless blood testing in performed. For these reasons, we always recommend blood screening before any anesthetic procedure. If you would like your pet to have pre-anesthetic blood work please let us know*
- Yes, I would like my pet to have pre-anesthetic blood work before anesthetic.
- No, I decline the recommended blood screening for my pet and am aware of the risks involved with anesthetic.
- Unsure, I have questions about pre-anesthetic blood work.
- Done previously
CONTACTING YOU DAY OF SURGERY:
Please indicate the best contact information where we can reach you on your pet's DAY OF SURGERY:*
Would you like us to text or email you?*
- Yes
- No
If yes, please confirm your cell phone number and e-mail address:
Sometimes we like to take a photo of patients during their visit with us. Do we have your permission to post your pet's photo on our Facebook page if we take a picture today?*
- Yes
- No
Received by: _______________________________________________________________________________
(Office use only)
Owner/Guardian Signature: _____________________________________________________________
(Owner signs here at pet's admittance)

Brockville Animal Hospital

681 Stewart Blvd.
Brockville, ON K6V 5T4

Phone: 613-345-3401
Email Us

Hours of Operation

Monday	8:00am – 8:00pm
Tuesday	8:00am – 8:00pm
Wednesday	8:00am – 5:00pm
Thursday	8:00am – 5:00pm
Friday	8:00am – 5:00pm
Saturday	8:00am – 4:00pm
Sunday	Closed

*We are closed Tuesdays between 1-2PM for staff training

Waterfront Veterinary Services

Limited hours of operation.
Please call for details.

26 Water Street, East
Brockville, ON K6V 1A1

Phone: 613-345-3401
Email Us

Emergency Info

For emergencies outside of regular office hours please call 613-345-3401 to reach our after hours emergency triage service.

For emergency care after 8:00 p.m. or Statutory Holidays please call:

Ottawa Animal Emergency & Specialty Hospital: 613-745-0123 or contact one of these emergency veterinary hospitals.

Emergency Hospital List

About Us
Services
Pet Health
Contact Us
- Online Consult
Shop Online
Book Appointment

facebook
linkedin
instagram

The Brockville Animal Hospital Team would like your help to evaluate your pet prior to anesthesia. Please complete this online form (below) and submit prior to your pet’s admittance.

(Printable form) If you require a printable form, please remember to bring this filled out form with you to the hospital for your pet’s admittance.

OWNER'S INFORMATION:

CO-OWNER'S NAME AND CONTACT INFO:

EMERGENCY CONTACT INFO:

PET INFORMATION:

PLEASE ANSWER THE FOLLOWING QUESTIONS:

PRE-ANESTHETIC BLOOD TESTING:

CONTACTING YOU DAY OF SURGERY:

Brockville Animal Hospital

Hours of Operation

Waterfront Veterinary Services

Emergency Info

(Printable form)
If you require a printable form, please remember to bring this filled out form with you to the hospital for your pet’s admittance.