Pet's Name *

Owner's Name *

First

Last

PROCEDURES WHILE ANESTHETIZED:

Radiographs (x-rays) of:

Mass Removal(s) List:

If other, then mention procedure:

Has your pet been Microchipped? Microchips are proven to be the best way to reunite you with your pet if he/she is lost or stolen. We can Microchip your pet under anesthesia and he/she will never know, but you will have peace of mind knowing that this could be the only way to reunite you with your pet if he/she is lost or stolen.

Yes, microchip my pet
No, do not microchip my pet

REQUIREMENTS FOR ANESTHESIA AND/OR HOSPITALIZATION

Vaccinations: All animals must be current on the following vaccines: Dogs – DA2PP or DAP3, Rabies, Parainfluenza & Bordetella, and Heartworm Test Cats – FVRCC, Rabies, Feline Leukemia or have been tested within the last year
Surgical Risk Reduction: All patients receiving anesthesia that are 7 years or older are required to have had a pre-surgical blood profile completed within one month of surgery to ensure anesthetic safety. These patients are also required to have an intravenous catheter placed to further decrease anesthetic risk. Although not required, these procedures are highly recommended for all patients younger than 7 years.
Pain Management: Your pet will receive an injection to aid in pain management before anesthesia today and also will receive oral medication to control pain for the next few days.

ANESTHETIC CONSIDERATIONS:

Is your pet on any medications? (if so, list & time of last dose)

Is your pet allergic to any medications? (if so, list)

Does your pet have any health problems? (if so, list)

If your pet is less than 7, would you like a pre-surgical blood profile run on your pet before anesthesia to further assess his/her anesthetic risk?

Yes, run a pre-surgical blood profile on my pet
No, do not run this profile and I understand that my pet is at higher risk for anesthetic incidents.

If your pet is less than 7, would you like an IV catheter placed to help maintain proper blood pressure and to allow easy access to a vein in case of a surgical emergency?

Yes, place an IV catheter for further safety
No, do not place an IV catheter and I understand that my pet is at higher risk for anesthetic incidents.

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Surgical Consent Form

Surgical Consent Form