Full range of
pet care and emergency  services

Cats
Dogs
Avian and
Exotic pets

Serving the
Los Angeles
Community
Since 1969

10737 Venice Bl.
Los Angeles, CA 90034
 (310) 559-3770

Center-Sinai Animal Hospital TimeSaver Form:
Drop-Off Form For Surgery, Dental and
Other Procedures that Require sedation
Fill in here and submit online, fax to (310) 559-9447, or print, fill in and bring in with your pet.
(You can also copy and paste into Word, and fill out on computer to bring in.)

Dr. Baum   Dr. Spira     Dr. Plechner     Dr. Marissa Williams

Date 

Pet's Name 

Client Name

**Number at which you can be reached today

Is this a new phone number that we should keep on file? Yes No
Has there been an address change?    Yes    No

SCHEDULED PROCEDURE/TYPE OF SURGERY

Other than the scheduled procedure, are there any other treatments that you would like us to perform while your pet is under anesthesia? (Place an "X" as needed)

Growth Removal     Check & Clean Ears Check & Clean Teeth
Check If Vaccines Are Current, Give Them If They Are Due 

Clip Nails  Shave Mats    Other     (Please describe below)


IF YOUR PET IS OLDER THAN 7 YEARS:

We tend to be cautious in administering anesthetics. We feel that performing some simple blood tests can help to ensure a safer anesthesia for older pets and can also detect some health problems before they become serious.

YES PLEASE PERFORM PRE-ANESTHETIC BLOODWORK. I AM AWARE THAT THERE IS AN ADDITIONAL CHARGE.

NOI CHOOSE TO DECLINE THE BLOODWORK FOR MY OLDER PET.

WOULD YOU LIKE YOUR PET TO RECEIVE AN INJECTION FOR PAIN RELIEF?

(It is appropriate depending on your pet's reaction to the procedure performed.)

This injection is an additional $35.00.

Yes, I would like my pet to have an injection for pain relief.  No, I decline any additional injections. Please leave it up to the Doctor's discretion.

DID YOUR PET EAT THIS MORNING?   YES            NO

(It's fine if your pet ate this morning. We will perform the procedure later when his/her stomach has had time to empty. Please note: your pick-up time may be later.)

IF YOU HAVEN'T BEEN GIVEN AN ESTIMATE FOR OUR SERVICES FOR YOUR PET,
PLEASE TAKE TIME NOW TO REVIEW COSTS WITH US.

 

*For Spay & Neuter Clinic Day, price quotes are for routine surgeries only. Additional charges apply for females in heat or pregnant and for males that are cryptorchid (have one or both testicles that have not descended). For Dental Clinic Day, price quotes are for routine cleanings and do not include additional fees that apply for extractions, infections of the mouth or heavy excessive tartar. *

I AUTHORIZE CENTER SINAI AND IT'S STAFF TO SEDATE MY PET AND PERFORM
THE PROCEDURE(S) THAT I HAVE REQUESTED ABOVE.

 


Client Signature (Please type in if submitting online. We will also need you to
sign personally in the office if you send this online.)              


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