Client Name *

Email *

Today's Date *

Date of Surgery *

Patient Name *

Age *

Patient History

Are vaccinations current? (Required for admission) *

Yes
No

Has your pet ever had seizures? *

Yes
No

Any coughing, vomiting, or diarrhea? *

Yes
No

Any illness in the past 30 days? *

Yes
No

Did your pet eat this morning? *

Yes
No

WOULD YOU LIKE A MICROCHIP? *

Yes ($45.00)
No
Already Has One

ISOFLUORANE: The anesthetic of choice for all surgical cases (except some feline procedures). Inhalant anesthetic patients are monitored with an ECG.

PRE-SURGICAL BLOOD TESTING is recommended to help reduce the risks involved with anesthesia. This test checks the internal status of your pet including liver and kidney function (these are the main organs that metabolize anesthesia), complete blood count and blood glucose level.

Pre-anesthetic panel w/ CBC $127.00 Recommended for pets under 7 yrs *

Yes
No

Comprehensive chemistry panel w/CBC $169.00 Required for pets 7 yrs and older *

Yes
No

Many pets experience vomiting following the administration of some anesthetic drugs. Cerenia can help prevent vomiting on the day of surgery, as well as to help them return to normal feeding sooner. This injection is an additional $72.00-$95.00. Would you like this for your pet? *

Yes
No

I, the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above and have the authority to execute this consent. I understand that during the performance of the procedure, an unforeseen situation may arise that necessitates an extension or variance in the procedure set above. I hereby authorize West Russell Animal Hospital to use reasonable care and judgment in performing the procedure. I have been advised as to the nature of the procedures and the risks involved in performing general anesthesia to the above described animal. I realize that results cannot be guaranteed. I have read and understand this authorization and consent. I further understand that I assume financial responsibility for all services rendered. I understand that all pets presented to West Russell Animal Hospital for a procedure must be current on vaccinations.

Cardiac Circulatory Pulmonary Resuscitation: I understand that risks and potential complications exist with anesthesia surgery and do not hold West Russell Animal Hospital liable for those risks. The attending veterinarian will perform any necessary emergency care and I agree to assume all financial responsibility associated with my decision. *

Yes
No

Owner Signature *

Telephone number you can be reached at for surgery: *