PREANESTHETIC SAFETY CHECK-IN QUESTIONNAIRE

Name

First Last

Phone

Email

Patient Name:

Are there any problems that you are aware of concerning your pet?

Yes
No

Previous anesthesia problems?

Yes
No

Pet medications given today?

Yes
No

Was food withheld?

Yes
No

What time was your pets last meal?

Microchips & Monitoring available for $60.00

Yes
No

Heartworm disease can be an anesthetic risk. We recommend a heartworm test today for your Canine $27.00

Yes
No

Additional Comments

Anesthetic Safety Screening

A physical exam will be performed on your pet prior to anesthesia. Some pets have internal problems that produce complications, yet are not evident on physical exam. These include anemia, lack of clotting, as well as liver, kidney, heart, or other conditions possible in any age pet. We recommend the following tests in order to decrease the chance of complications. (These tests are the same as some performed on humans before any anesthetic procedure). As with any surgery requiring general anesthesia, there are certain risks that serious complications or even death may result.

We recommend the pre-anesthetic blood test be performed prior to administration of anesthesia in Patients less than 7 years of age and REQUIRED in Patients over 7 years of age. These tests can help us detect anemia, dehydration, diabetes, kidney disease, and liver disease. All these conditions can contribute to complications in anesthesia and surgery.

CBC ($34.00)
CBC, SDMA and Kidney levels ($69.50)
Chem 10 Panel. ($54.00)
CBC and Chem 17 Panel ($75.00)

The doctor highly recommends having an IV catheter placed and fluids administered to Patients less than 7 years old and REQUIRED in Patients over 7 years old. IV fluids aid in maintaining adequate blood pressure and help internal organs flush out anesthetics and bacteria released during the procedure. ($45.00)

Yes
No

In order to provide a greater level of comfort, I would like my pet to receive a post-surgical injection for pain relief. ($22.00-$35.00)

Yes
No

In addition to the pain injection, we offer an oral medication to provide your pet with an added source of comfort after surgery. This will be sent home with your pet. ($14.00-$24.50)

Yes
No

Would you like to have laser therapy performed post operatively to speed healing and reduce pain and inflammation? The cost is $20*

Yes
No

Some animals may lick or chew at the incision after surgery. This can be serious especially in females. We offer a collar to prevent this problem. ($15.00-$20.00)

Yes
No

Consent

I hearby authorize and direct the veterinarians of Alamosa to perform the procedure and additional diagnostic and/treatment procedures as deemed advisable for the Patient. The nature of the procedure has been explained to me and no guarantee has been made as the result or cure. I understand that the risk of death can occur during any anesthetic and/or surgical procedure. I agree to pay, in full, for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. Any estimates or charges for the planned procedures are only approximations, and the final bill may be greater or less than these amounts. All services must be paid for when the Patient is released. Some procedures require a deposit to be made before surgery.

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