 *Full Name
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*Patient Name
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*Date of Procedure
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*Procedure/Reason for Admittance
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Medical History: Please answer with yes, no, or n/a and explain any yes answers. |
*Has food and water been withheld?
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*Has your pet had any recent illness or injury?
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*Any history of chronic conditions? (diabetes, seizures, heart disease)?
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*Is your pet currently taking any medications prescription or over the counter (please list medications, dosage, and frequency)?
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*Is your pet allergic to any medications?
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*Has your pet been anesthetized previously? If yes, any problems?
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*Do you with that pre-anesthetic blood test be conducted? (These tests are mandatory for any geriatric pet).
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*If this is a spay procedure and your pet is found to be pregnant, how would you like us to proceed? stop surgery, continue surgery, n/a
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*Is patient up to date on vaccines?
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*Has patient ever experienced a vaccine reaction? If yes, what vaccine(s)?
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*Is patient on monthly heartworm prevention? If yes, what type?
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*Would you like to be contacted at the completion of the surgery? If yes, please provide a phone number.
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*Emergency Contact: Please list the name and phone number of someone we can contact if we cannot reach you at the number listed above.
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If your pet is found to have fleas, you will be responsible for the cost of treatment. If you have any questions concerning your pet or this procedure, please inform your technician at the time of admittance. |
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