Please fill out our Surgery Form using one of the options below if your pet is having a surgical procedure at Brogli Lane Weaver & Alexander Animal Hospital.

Option 1

Complete Online

Complete and submit the online form below.

Option 2

Print & Complete

Bring the completed form with you to our hospital.

Download Form

Option 3

Complete on Arrival

If you prefer, fill out the form when you get to our hospital.

Surgery Form

Owner Name *

Phone *

Email Address *

Patient Name *

Procedure *

Please read the form & provide the requested information

I hereby authorize Brogli, Lane, Weaver & Alexander Animal Hospital to perform the above procedure and any associated treatment procedures deemed advisable or necessary for my pet. The nature of the procedure has been explained to me and I realize that neither a guarantee nor warranty can ethically or professionally be made regarding the results or cure.

Further, I understand that I assume financial responsibility for all services rendered and that payment is due on the date of surgery.

I am the owner or authorized agent of (pet name) *

All animals admitted must be current on their vaccinations and must be free of external parasites. Any animal found to have fleas, ticks, or other external parasites will be treated at the owner's expense. All animals are shaved on a leg for IV catheter placement.

Owner or authorized agent name *

Medical History

Please select yes or no if you pet has

Vomited or had diarrhea in the last 48 hours *

Coughing or sneezing out of the ordinary in the last 7 days *

Eaten in the last 10 hours *

Recently shown any signs of exercise intolerance *

Any change in eating or drinking habits in last 30 days *

Allergic to any medications *

Been diagnosed with a heart murmur or heart condition *

Been diagnosed with any liver or kidney problems *

Ever had an adverse reaction to anesthesia to your knowledge *

Had any medication in the past 24 hours *

Experienced any trauma in the past 7 days *

Major weight gain or loss recently? *

Have any medical problems that we do not know about *

Is your pet current on vaccines and deworming *

Is your dog current on heartworm prevention *

List any medications you pet is currently taking *

If you answered yes to any question above, please provide further details *

Laboratory Test Waiver

Advances in anesthesia and surgery have made routine procedures relatively safe with a low rate of complications, nevertheless, occasional problems can arise due to preexisting conditions not evident during routine pre-anesthetic examinations. Many anesthetic medications used on your pet are metabolized in the liver and eliminated through the kidneys. Any issues that could affect the function of these organs can cause serious harm to your pet and interfere with normal anesthetic recovery. To help avoid these problems, we recommend a blood profile. Results of these tests will help determine your pet's readiness for surgery. ALL surgical procedures do include risks with anesthesia. These tests will be performed (and you will be charged) unless you refuse them.

Please select yes or no to choose which bloodwork option you would like. IF YOUR PET IS OVER 5 YEARS OF AGE-- BLOODWORK WILL BE REQUIRED IN ORDER TO ENSURE SAFETY FOR OUR OLDER PATIENTS!

Pre-Operative Bloodwork - This is a bloodwork that analyzes your pet’s circulating blood cells, measures protein, glucose, electrolyte levels and checks your pet's basic liver and kidney health. Abnormalities in any of these values can affect your pet while under anesthesia. *

General Surgical Bloodwork - Like the pre-operative bloodwork, this panel will analyze your pet's circulating blood cells and check liver and kidney health. Unlike the previous option, this choice will test your pet’s cholesterol and extra liver values that could indicate a function problem that the pre-operative choice could not find. Also included here are tests of the phosphorus and calcium levels. Alterations to these levels are commonly observed with certain cancers and metabolic diseases. This panel will also screen for pancreatic disease. *

Complete Surgical Bloodwork - If you want the best option for your pet, this is our most comprehensive panel. This option is a combination of the General Health Bloodwork plus a thyroid level test. Thyroid level analysis is very important in our older patients or at-risk patients. Commonly in these patients, this level can be altered, which does affect overall pet health and can delay post-surgery healing. *

I choose NOT to do any bloodwork - I am choosing not to have any bloodwork run on my pet today. My pet is UNDER 5 years old or my pet has had bloodwork in the last 6 months. I understand the risks of waiving pre-surgical bloodwork and take full responsibility if any complications occur that could have been prevented due to having had bloodwork prior to surgery. *

For your convenience, please check any service below that you would like for us to do while your pet is here! Please note that charges will apply for add-on services

Nail Trim

Vaccines (any that your pet may be do for)

Heartworm Test

Microchip

Anal Sac Expression

Ear Cleaning, Flushing, Medication

Ear Hair Removal

X-Ray for arthritis or tumor screen

Biopsy of Tumors or Lumps (per Doctor discretion)

**ALL patients receive pain medication prior to surgical procedures**

I understand that I assume financial responsibility for ALL services rendered and/or agreed upon. Payment is due on the date of the surgery. Any medications and supplies purchased will be at an additional charge. If we are unable to reach you at the emergency contact number, we will do what is medically necessary at the owner's expense.

Owner/ Agent Name *

Date

Spam Blocker

Surgery Form

Option 1

Complete Online

Option 2

Print & Complete

Option 3

Complete on Arrival

Surgery Form

Please read the form & provide the requested information

Medical History

Laboratory Test Waiver

Caring for Pets in Murfreesboro