South Crossing Veterinary Center

6700 Kalamazoo Ave. SE.   Grand Rapids, MI 49508

Client Name: ___________________________________ Pet's Name: _____________________

Date _______________ Contact Numbers: ___________________________________________



Surgery to be performed: _________________________________________________________



Policies for surgical admitting:

* Pets must be current on all preventative health care.  Dogs require: Distemper, Bordatella and Rabies vaccinations, as well as

   heartwork testing.

* Fleas are not tolerated here. If your pet has evidence of fleas they will be treated at your expense.
* We reserve the option to decline performing surgery on animals that are aggressive or have any health problems that would

    preclude anesthesia.
* Surgical drop offs are from 8 until 9am. Pick-ups from surgery will be arranged at drop off time.



Pre-surgical Blood Testing:

Your pet's blood is one of the largest organs and the easiest to examine. Many diseases and disorders can be identified in the blood

before anything else can be seen.  By examining your pet's blood before surgery we can often identify problems before they affect

them. Blood testing is routine in human medicine, and has helped make surgery safer and led to longer life for humans.  We strive for

these goals for your pet as well.


Please perform the age appropiate testing                   Up to 1 year..........................$55.00

on _________________ before anesthesia                   From 1 to 6 years................. $74.00

 Yes     No                                                                  From 6 years on (required)...$96.50



Would you like ______________________ to recive a post-operative pain relief?

 Yes     No                 (ask for cost estimate)

Would you like pain relief medication for the at home recovery period? 

 Yes     No                 (ask for cost estimate)

Would you like the surgery on ________________________ to be performed with a LASER?

 Yes     No                 (ask for cost estimate)

(the use of a LASER greatly reduces blood loss, swelling and pain)



Would you like _______________________ to recive any of the following Available Services?

(Costs are reduced when under anesthesia)

*  Nail trim                                 Yes     No               (Cost: $9.70)

*  Ear cleaning                            Yes     No               (Cost: $12.10)

*  Anals checked/expressed        Yes     No               (Cost: $13.47)

*  Teeth cleaning                        Yes     No               (Ask for estimate)

*  Bathing or skin care                Yes     No               (Ask for estimate)

*  Microchip ID                         Yes     No               ($43.00 chip cost, $19.99 registration) 

OWNER RELEASE:  South  Crossing Veterinary  Center is  to use all  reasonable precautions against

injury, escape, or death of ________________________.  I understand that all anesthesia and surgery

involves risk to my pet and that South Crossing Veterinary Center and its representatives will not be liable

for any adverse outcome.  It is thoroughly understood that I assume all risks. I agree to pay in full all costs

when I pick up ________________________.

I have read the foregoing and agree.



Signature of the above animal's owner or authorized agent                     Telephone:


____________________________________________                  _______________________