Pre-Surgical Admittance Form – Brockville Animal Hospital

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Your pet will be undergoing a general anesthesia today. The doctors and staff at the Brockville Animal Hospital would like your help evaluating your pet prior to anesthesia by completing this form and submitting prior to your pet’s admittance. Please answer the following questions:

Pre-Surgical Admittance Form – (Printable version)

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
Day-Time Phone*
Evening Phone
Mobile Phone
Email*
Enter Email Confirm Email
CO-OWNER'S NAME AND CONTACT INFO:
Name
First Last
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
Do you have pet insurance?*
- Yes
- No
If yes, what is the name of your pet insurance provider?
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.
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)
Untitled

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

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