Canine General Surgery / Anesthetic Release

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.



Layout

Owner *

Pet’s Name *

Procedure

What medications is our pet currently on? (Ex. Aspirin):

Has your pet ever had a seizure?

Animals scheduled for routine surgery must have been fasted for at least 12 hours prior to the procedure. Please indicate below the last time your pet ate.

Last Feeding:

Our practice does offer an In-Clinic Pre Anesthetic Blood-work:

Chemistry Profile and Electrolytes: To check organ function (Consists of: ALB. ALKP. ALT. TBIL.. BUN. CREA. GLU. NA+. K+. TP and GLOB)

Accept
Decline

CBC: To check for hydration. anemia. adequate platelets. Inflammation and Infection. (Consists of HCT. HGB. MCHC. WBC, GRANS. L/M. AND PLT)

Accept
Decline

Heartworm test

Accept
Decline

Heartworm plus screen for tick diseases — Ehrlicia, Le me, Anaplasma Test

Accept
Decline

IV Catheter and Fluids help to keep your pet hydrated and organs perfused during a procedure. Required for pets 7 years of age and older.

Accept
Decline

We can Microchip your pet

Accept
Decline

Doctors and staff will use all reasonable precaution against injury, escape and death of your pet. Please understand that anesthesia involves some risk to your pet and that you assume all risk, and cost incurred if Pre- Anesthetic Blood-work is declined.

Email *

Layout

Date *

Owner’s Contact Number: *

Signature of Owner

Clear Signature

phone

E-mail

phone

E-mail

Canine General Surgery

Canine General Surgery / Anesthetic Release

Ready to Visit Us?

Have Any Questions?

Address

Hours

Contact

We proudly serve…