Surgical Patient History Form and Authorization

Name: Veterinarian
Brand: Burr Ridge Veterinary Clinic

Thank you for giving the team at Burr Ridge Veterinary Clinic the opportunity to care for your animal companion. To help make check-in faster, please complete the following Surgical Patient History Form and Authorization at least two days prior to your pet’s appointment.

You may complete the web form and submit it online below or click the Download PDF Version button to download the form and submit it to [email protected].

How to download and email the PDF form:

Open the fillable PDF version of the form by clicking the button below.
Download the blank form to your computer.
Complete the fillable PDF form using your computer’s PDF reader program
Save the completed form as a new file and e-mail it to [email protected] as an attachment.

If you have any questions or issues with the form, please call us at 630-598-0600.

Download PDF Version

Date

Your First Name

Your Last Name

Pet's First Name

Pet's Last Name

Phone number where you can be reached AT ALL TIMES on the day of surgery

Secondary Phone

Has your pet been in contact with any COVID-19 positive person in the past two weeks?

Yes

Is your pet experiencing any other issues or do you have any additional concerns you would like the doctor to address today?

If we are NOT able to reach you and have a question about your pet; what would you like us to do?

Proceed with what the doctor recommends

Do not do anything that I have not authorized. I understand that may mean waking up my pet and not performing the scheduled procedure

Signature

Sign above

Surgical Patient History Form and Authorization

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