Owner's name *

First

Last

Email *

Pet's name *

Procedure being performed *

Time of last food *

Time of last water *

Is your pet on any medication? *

Yes
No

If yes, please list the name of the medication(s) and the last time given. *

Any other treatments needed while here? *

Yes
No

Please specify. *

Would you like your pet to be microchipped today? *

Yes
No

Any belongings left with your pet? *

Yes
No

Please describe items. *

Will someone else be picking up your pet? *

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No

Name *

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Last

A pre-anesthesia blood screen is recommended for all pets but is required for pets 7 years of age and older, prior to anesthesia. If all of the tests are normal, it does not guarantee that your pet will not have an anesthetic reaction, but it does tell us that your pet is healthy and in a low-risk category. If any of the test results are abnormal, the doctor will call you to discuss how to proceed. This blood screen includes the following tests:

Complete blood count: Detects anemia, infections, and clotting disorders

Bun and Creatine: Assesses kidney function

Glucose: Detects diabetes

ALT & ALKP: Assesses liver function

Total protein: Detects dehydration

Would you like your pet to receive a blood screen? *

I do.
I do not.
Blood screen was done within past 30 days.

For pets having dental procedures:

After examining your pet under anesthesia, the doctor may recommend additional treatment, such as extractions. In some cases, once dental calculus has been removed, underlying disease can be revealed. Extractions of diseased teeth may involve additional local anesthetics, gas anesthesia, and dental surgery time which commonly range in cost from $100 to $500. If such treatment is recommended, would you like us to: *

Proceed with treatment
Proceed up to a certain amount (specify below)
Contact you with an estimate
My pet is not having this procedure

Maximum amount authorized *

For pets having surgical removal of masses:

We recommend sending tissue sample of masses in almost all cases. These samples go to an outside lab for further study. This study can determine the nature and behavior of tumors and determine if appropriate surgical margins were taken. *

Proceed with histopathology ($75 - $160, depending on lab)
Contact me to discuss histopathology options
My pet is not having this procedure

For pets having general surgery (spays, neuter, etc.):

We understand you have been given an estimate for a surgical procedure and will take all steps necessary to meet that goal. There are rare occasions in which additional treatment is needed for previously unknown conditions or complications. If this situation occurs, we will attempt to contact you with your provided phone number. If we are unable to reach you, would you like us to: *

Proceed with treatment
Wait until contacting you to discuss additional treatment
My pet is not having this procedure

Date *

Anesthesia Form

Please complete this form before your visit.

Anesthesia Form

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