Pre-Hospitalization Questionnaire – Small Animal Clinic At Piedmont Equine

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EMERGENCY INFORMATION
540-364-4954
office@piedmont.vet
The Piedmont Equine Practice

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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:
Owner's name:
First Last
Best contact number (text or phone call?):
Emergency Contact Method:
- Text
- Phone
Emergency contact number:
(in case you cannot be reached)
Intended procedure(s):
Additional Procedures
Select any additional procedures:
- Pre-anesthetic lab work ($115)
- Express anal glands ($41)
- Microchip ($55)
- Nail trims (complimentary with surgery or $28)
Please list current medications and last dose given:
In the case of mass removal(s); please describe the site(s) or mark with a Sharpie/Tape:
(Biopsy ≈ $232)
In the case of dental treatments, would you like to be contacted prior to any extractions?:
- Yes
- No
If YES, please be available by phone, if you are unable to be reached in a timely manner, we will proceed with any needed extractions.
- Agree
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 judgment.*
- 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.
In the event your pet arrests while at our hospital, you accept or decline CPR to be performed.*
- Accept
- Decline
Signature*
First Last
Date*
Date Format: MM slash DD slash YYYY

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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

Equine

© 2025 Small Animal Clinic At Piedmont Equine .
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Home
About Us
Pet Services
Caring for Your Pet
Pet Health
Pet Portal
Contact Us
- Emergency
Pharmacy & Pet Food

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