Cat Spay/neuter Surgery Check-In Form printable pdf download

Spay/Neuter Surgery Check-In Form

Office Use animal ID #___________

Owner Information:

First Name:________________________________

Last Name:____________________________________________

Street Address:_____________________________________

City:____________________

ZIP:________________

Home Phone:________________________ Cell Phone:___________________________

Best Number in case of Emergency:___________________________

Email:_________________________________

Pet Information:

Name:___________________________

Sex: ❑ M

❑ F

Age:_____________

Color:____________________

Date of last FVRCP vaccine:______________________ Date of last Rabies___________________

To your knowledge is your pet: ❑ Pregnant ❑ In Heat

❑ Overweight

❑ Lactating

1. What illnesses has your animal had in the past? ❑ Coughing

❑ Sneezing

❑ Vomiting

❑ Diarrhea

❑ Not eating/drinking

❑ Other ____________________________________________________________________

2. Does your animal have any of the above problems now? ❑ No ❑ Yes _____________________________________

3. Has your animal had any serious injuries in the past? (Broken bone, hit by car) ❑ No

❑ Yes____________________

4. Has your animal ever had any surgery, seizures(epileptic fit), abnormal bleeding, fainting or bruising?

❑ No

❑ Yes ___________________________________________________________________________________

5. Has your animal ever had an allergic reaction to an insect bite, vaccine, anesthesia, or medication?

❑ No

❑ Yes ___________________________________________________________________________________

6. Is your animal taking any medication? (antibiotics, allergy meds etc) ❑ No

❑ Yes ____________________________

7. Has your animal ever had any kidney, liver or heart problems? ❑ No

❑ Yes ________________________________

8. Does your animal currently have fleas or ticks? ❑ No ❑ Yes Been treated with flea treatment? ❑ No ❑ Yes

9. Is your animal friendly? ❑ Yes

❑ No

10. Has your animal been to a veterinary facility before? ❑ Yes – Vaccine clinic only

❑ Yes Veterinary Hospital ❑ No

11. How long have you had your cat? __________________________________________________________________

12. When was your cats last meal? (includes treats, scraps etc…) ___________________________________________

13. Females only - Has your animal had a litter before? ❑ No

❑ Yes How many kittens? _________________________

14. Has your animal bitten anyone in the last 10 days? ❑ Yes

❑ No

Your animal will receive a pre-surgery examination, rabies vaccination if needed and nail trim(no charge)

Owner’s Printed Name_______________________________

Owner’s Signature____________________________

Cat Spay/neuter Surgery Check-In Form

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