Pre-Hospitalization Questionnaire

Thank you for taking the time to prepare for your pet’s visit to our clinic. The more information we have, the better we can help you with your pet’s health! For surgery and dental procedures your pet can not have any food after midnight, but can have water. Drop off is between 8:15 and 9 AM.

Your pet’s name:
Your name:
First Last
Best contact number (text or phone call?):
Text or phone call:
- Text
- Phone
Emergency contact number:
(in case you cannot be reached)
Intended procedure(s):
Additional procedures:
- pre anesthetic lab work ($105)
- express anal glands ($39)
- microchip ($52)
- nail trims are complimentary for pets having surgical procedures, $26 otherwise
Our doctors highly recommend performing bloodwork prior to all procedures to ensure your pet is a healthy candidate for anesthesia. This blood work will inform the doctors of any underlying unknown health conditions, such as clotting disorders, early organ dysfunctions that can be worsened by anesthesia, or pre-existing infections (including some parasitic infections)*
- I (accept)
- I (decline) performing pre-procedure bloodwork today
Please note: If your pet is greater than 6 months of age and due for a Heartworm and Tick Panel, this will also be performed prior to his or her procedure and is separate from the pre-operative panel
In the case of mass removal(s); please describe the site(s) or mark with a Sharpie:
(Biopsy ≈ $189)
In the case of dental treatments, would you like to be contacted prior to any extractions?:
If so, please be available by phone, if you are unable to be reached in a timely manner, we will proceed with any needed extractions. Please list current medications and last dose given:
Diet, including treats and dental chews:
Has your pet been fasted?:
Any known allergies?:
Any prescription refills needed?:
Any vaccines needed?:
Any post op calming medications needed?:
Any handling/behavioral concerns?:
Any other concerns at this time?:
I hereby consent to and authorize the performance of the above procedure(s):
Should any medical emergency arise while my pet is in the care of The Small Animal Clinic at Piedmont Equine, and I or my emergency contact cannot be reached to provide authorization for treatment, the attending veterinarian will proceed to stabilize my pet in a conservative, reasonable manner according to their professional judgement. (PLEASE ONLY CHOOSE ONE)
- I authorize emergency treatment if required and agree to pay any additional expenses incurred for such treatment.
- I do not approve any additional emergency treatment.
Name
First Last
Date
Date Format: MM slash DD slash YYYY

Exceptional veterinary care in The Plains, VA

Below you will find contact information for our veterinary practice in The Plains. Please call us to make an appointment- 540-364-4954.

Address

4122 Zulla Road
The Plains, Virginia, 20198

Contact

Phone: 540-364-4954
Fax: 540-364-4987
Email: office@piedmont.vet

Hours

Monday -Friday 8:00am – 6:00pm
Saturday-8:00am – 12:30pm
Sunday-Closed

EMERGENCY INFORMATION