Patient Information Form Client InformationName:Primary Phone:Address Street Address City ZIP / Postal Code Emergency Phone:Email Patient InformationName: Canin Feline Male Female AgeColorBreedHas your Pet Shown any Signs of Illness? Vomitting Diarrhea Coughing Sneezing Change in Appetite On Any Meds? Has Your Pet Had Any Previous Reactions to Vaccinations, Medication, or Anesthesia?YesNoPlease DescribeIf Pet is Pregnant Do You Wish to Continue with Surgery?YesNoDental Extractions are Necessary in Some Dentals. Do You Authorize Extractions:YesNoCIRCLE AUTHORIZED SERVICES CAT NEUTER $70.00 Cat Spay $95.00 Dog Neuter Less Then 35LBS. $95.00 Dog Neuter 36-50 LBS. $104.00 Dog Neuter 51-75 LBS. $132.00 Dog Spay Less Then 35 LBS. $105.00 Dog Spay 36-50 LBS. $124.00 Dog Spay 51-75 LBS. $150.00 Pre-Anesthetic Panel $95.00 Micro Chip (No registration Fee) $50.00 Cryptorchid Charge $50.00 Obese Charge $50.00 In Heat Charge $45.00 - $75.00 Pregnant Charge $75.00 Aggressive Dog Charge $70.00 Ear Mite Treatment $32.00 Heartworm Test (4DX) $50.00 Feline Hwt/Felv/Fiv Test $50.00 Deworming $20.00 Flouride TX $30.00 Cat Vaccine Package $70.00 Dog Vaccine Package $70.00 Rabies Only $35.00 E-Collar $25.00 Fecal Analysis $80.00 Injection Package $44.00 Medication Package $44.00 Dental Prophylaxis w/anesthesia 9 and Linder $299.00 Dental w/Other Procedure $190.00 Toe Nail Trim $20.00 CAT NEUTER Price: $70.00 Cat Spay $95.00 Price: $95.00 Dog Neuter Less Then 35LBS. $95.00 Price: $95.00 Dog Neuter 36-50 LBS. $104.00 Price: $104.00 Dog Neuter 51-75 LBS. $132.00 Price: $132.00 Dog Spay Less Then 35 LBS. $105.00 Price: $105.00 Dog Spay 36-50 LBS. $124.00 Price: $124.00 Dog Spay 51-75 LBS. $150.00 Price: $150.00 Pre-Anesthetic Panel $95.00 Price: $95.00 Micro Chip (No registration Fee) $50.00 Price: $50.00 Cryptorchid Charge $50.00 Price: $50.00 Obese Charge $50.00 Price: $50.00 In Heat Charge $65.00 Price: $65.00 Pregnant Charge $75.00 Price: $75.00 Aggressive Dog Charge $70.00 Price: $70.00 Ear Mite Treatment $32.00 Price: $32.00 Heartworm Test $50.00 Price: $50.00 Feline Hwt/Felv/Fiv Test $50.00 Price: $50.00 Deworming $20.00 Price: $20.00 Flouride TX $30.00 Price: $30.00 Cat Vaccine Package $70.00 Price: $70.00 Dog Vaccine Package $70.00 Price: $70.00 Rabies Only $35.00 Price: $35.00 E-Collar $25.00 Price: $25.00 Fecal Analysis $80.00 Price: $80.00 Injection Package $44.00 Price: $44.00 Medication Package $44.00 Price: $44.00 Dental Prophylaxis w/anesthesia 9 and Linder $299.00 Price: $299.00 Dental W/Other Procedure $190.00 Price: $190.00 Toe Nail Trim $20.00 Price: $20.00 Total $0.00 SoapWeightTempHR:RR:MM/CRTNotes:DR. INITIALS:GA: N AB MUSCULO: N AB ABD: N AB RESP: N AB EYES: N AB ORAL: N AB INT: N AB CIRC: N AB GU: N AB EARS: N AB LYMPH: N AB NEURAL: N AB SurgeryPre-MedsAmountRouteInitialsTime Atropine 0.54 MG/MLACE Promazine. 10 MG/MLHydromorphone 2MG/ML Anesthesia:Tube Size:Sevoflurane:Telazone:Initials:T/P/R:TIME:INITIALS:T/P/R:TIME:INITIALS:T/P/R:TIME:INITIALS:T/P/R:TIME:INITIALS:Recovery T/P/RAwake Time:Tech Initials:Injections:Medications:Peniollin 300,000 U/MLRimodyl 50 MG/MLHydromorphine 2MG/ML I understand that the staffs at 101 spay and neuter clinic will take reasonable precautions against Injury, escape or death of my pet, but will not be held responsible or able in any way in connection herewith as it is thoughrly understood that I the owner/ authorized agent assume all risks. I am aware that 101 spay and neuter clinic does not provide 24 hour care. SignatureDate
