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Westosha Veterinary Hospital Salem, Wisconsin
Contact Us
26851 75th Street
Salem, WI, 53168
Phone:
(262) 843-4271
Fax: (262) 586-5163
Email Us
EMERGENCY/AFTER HOURS CARE
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Surgery/Dental Check-In Form
Home
» Surgery/Dental Check-In Form
Surgery/Dental Check In Form
Owner Name
First
Last
Pet Name
Species
--SELECT--
Dog
Cat
Other
What procedure is your pet scheduled for?
--SELECT--
Surgery
Dental Cleaning
Is your pet currently on any medications (including homeopathic or supplements)?
--SELECT--
Yes
No
What medications and how often are they given?
When was the last dose given?
Refills needed?
--SELECT--
Yes
No
Please withhold food from your pet from 8pm starting the night before the procedure. It is ok to offer water until the morning of procedure.
PreAnesthetic bloodwork is strongly recommended prior to any anesthetic procedure to ensure that your pet is in a low-risk category prior to anesthesia. The results of these tests also serve as a baseline reference value should your pet become ill in the future.
If your pet is middle-aged (5 years) or older, current bloodwork is required before any anesthetic procedure. (If it has been longer than 6 months since your pet’s last blood panel, the doctor may require it).
If your dog weighs 25 pounds or less, bloodwork is required before any anesthetic procedure.
If your pet weighs 26 pounds or more, and is 0-4 years old, would you like us to run preanesthetic bloodwork on your pet today? The cost is $96.00.
--SELECT--
Yes
No
All dogs must have a current heartworm test.
All cats must have a negative FIV/FeLV/HWT on file.
All Growth Removal Surgeries: If all growths or lumps to be removed are not obvious, please shave the fur or mark all growth locations with nail polish or a permanent marker.
All Growth Removal Surgeries: If the doctor recommends a histopathology of tissue from the growth (the presence or absence of abnormal cells), Westosha Veterinary Hospital has permission to send the sample to the lab for pathologist review. We usually have results within 1 week. The cost for this is $138.
Permission for pathologist review
--SELECT--
Yes
No
K-laser treatment. We offer post-surgical or post-dental laser therapy treatment for $30. This is the use of wavelengths of light (red and near-infrared) to create therapeutic effects. These effects include improved healing time, pain reduction, increased circulation, and decreased swelling.
Would you like us to perform laser therapy on your pet today for pain and inflammation after his/her procedure? The cost is $45.10.
--SELECT--
Yes
No
(Laser is not performed on growth/lump removal surgeries)
Your pet’s vital signs (heart rate, blood pressure, respiratory rate, oxygen status, ventilation and temperature) are monitored continuously throughout the procedure. There is still always a risk when undergoing anesthesia.
Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff has my permission to perform CPR and I agree to pay for such services.
--SELECT--
Yes
No
Do you need a refill of flea and tick and/or heartworm preventative?
--SELECT--
Yes
No
If so, how many months worth and what type do you need?
If your pet is not already microchipped, we can place one today while your pet is under anesthesia. We use Home Again microchips and register your pet for life. The total cost for this is $50.99. This includes a $5 discount for microchipping under anesthesia.
Would you like us to microchip your pet today?
--SELECT--
Yes
No
If we are microchipping your pet today, please provide an alternate emergency contact person to have on file in case you cannot be reached if your pet ever gets lost.
Alternate Contact Name:
First
Last
Alternate Contact Phone #
Pets undergoing surgery or dental procedures usually go home after 3pm. Do you have a preferred pick-up time today?
Best phone number for us to reach you when your pet is in recovery:
Please call us at (262) 843-4271 when you arrive. Please remain in your car. Please put your face mask on when we come out to get your pet. Thank you for your patience during this challenging time!
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