Surgery Drop-off Form

Please complete the form below to ensure we have the most accurate and up-to-date information.

Owner's Name *

First

Last

Email *

Pet's Name *

Phone number at which owner can be reached: *

Additional Number: *

When was the last time pet was fed? *

Would you like us to text you after the procedure, or would you prefer a call?

Text
Call

Would you like us to microchip your pet during the procedure? (There is an additional fee)

Yes
No
Already has one.

I am over 18 and understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. I do hereby give Willapa Veterinary Service, agents, doctors, and/or representatives the full, and complete authority to perform the surgical procedure If unable to contact me, the staff may or may not have my permission to proceed with life sustaining procedures. While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above. *

I have read and agree.

Signature *

Clear Signature

Date *

We are accepting new patients!

Surgery Drop-off Form

Surgery Drop-off Form

We’d love to see you! Schedule your visit today.

Our Main Clinic

Raymond

Our Satellite Clinic

Grayland

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