Owner Name *

First

Last

Cat’s name *

Procedure to be performed *

Do you have any concerns today? *

Has your cat been vomiting? *

Yes
No

Has your cat had diarrhea? *

Yes
No

Has your cat been coughing? *

Yes
No

Has your cat been sneezing? *

Yes
No

Any change in appetite? *

Yes
No

Any change in behavior? *

Yes
No

Additional services requested:

Nail trim – no cost *

Yes
No

Ear Cleaning ($22.75) *

Yes
No

Hygiene Trim ($27.00) *

Yes
No

Microchip Implantation ($38.00) *

Yes
No

Ear tip (recommended for stray/feral cats at time of spay or neuter – no cost) *

Yes
No

I hereby authorize The Cat Doctor of Monroe and Dr. Kimberly Scutchfield to use sedation and/or general anesthesia on my pet. I understand that sedation and anesthesia pose a risk to my pet, regardless of health status. In the event of unforeseen complications, I give permission for the doctors and staff to take reasonable measures in treating my pet and accept all charges that are incurred as a result of such action. As the owner or appointed caregiver, I understand that by signing below, I agree to pay for all charges +/-15% of the fees for my pet’s procedure and will pay the balance in full upon discharge of my pet. The sedation and/or anesthesia and relevant procedure costs have been fully explained to me to my satisfaction. If there is evidence of fleas (live fleas, flea feces) we will administer a flea treatment to your cat and you will be responsible for the cost of the medication.

Payment is expected at the time of service. How will you be paying today? *

Cash
Credit/Debit
Check
Care Credit - minimum $200 transaction

I acknowledge that I am leaving my cat under the care of the staff at The Cat Doctor of Monroe. I understand that this facility is not staffed 24 hours per day and is not staffed on the weekends or holidays and that there could be complications which may become serious if not detected right away and may result in further injury, illness or death to my cat. I understand that I have the right to transfer my cat to the emergency center for 24 hour care at any time. I also understand that if an emergency does arise where I cannot be reached, the doctors and staff of The Cat Doctor of Monroe have the authority to treat my cat as deemed necessary to stabilize him/her. *

I have read and understand.

Owner signature: *

Date *

Please provide us with the best phone numbers to reach you today:

1. Phone Number *

2. Phone Number

Preferred method of contact (you can select more than one) *

Text
Phone Call
Email

Email *

Surgery Drop Off Questionnaire

Please complete this form before your visit.

Location

Contact Us

Hours

We are a cat-only veterinary hospital in Monroe, MI.

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