Conroevets - Pre-Anesthesia Questionnaire & Consent Form

1
* This field is required.
First Name
Last Name
Email
Pet's Name
Phone Number
2
Secondary number
Please list a number you can be reached it
Name of the person they will be calling at the secondary number
3
Your pet will be undergoing general anesthesia for this procedure. There is an inherent risk associated with anesthesia. Regardless of age, breed, species, or previous anesthetic experiences there is not a 100% guarantee that your pet will not have a complication during surgery that could lead to death. However, the Doctors and Staff at the Stone Ridge Veterinary Medical Center Conroe take this into consideration and evaluate each patient before, during and after anesthesia.
4
Have you noticed any changes in
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Appetite
Thirst
Energy Level
Exercise Tolerance
Breathing Pattern
Body Condition
Appetite
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
1 of 6
5
Have you noticed any changes in your pet's appetite?* This field is required.
Yes
No
6
Please describe the changes in your pet's appetite* This field is required.
7
Have you noticed any changes in your pet's thirst?* This field is required.
Yes
No
8
Please describe the changes in your pet's thirst* This field is required.
9
Have you noticed any changes in your pet's energy level?* This field is required.
Yes
No
10
Please describe the changes in your pet's energy level* This field is required.
11
Have you noticed any changes in your pet's exercise tolerance?* This field is required.
Yes
No
12
Please describe the changes in your pet's exercise tolerance* This field is required.
13
Have you noticed any changes in your pet's breathing pattern?* This field is required.
Yes
No
14
Please describe the changes in your pet's breathing pattern* This field is required.
15
Has your pet had any* This field is required.
YesNo
YesNo
Diarrhea
Vomiting
Diarrhea
YesNo
YesNo
1 of 2
16
We are trying to prevent your pet from vomiting and inhaling stomach contents during surgery. It will also lessen nausea in your pet as they regain consciousness.
When was the last time your pet had any food?
Please Select
Please Select
Yes
No
Has your pet ever had any kind of reaction or problem with anesthesia?
Anything else we should know about your pet before the anesthetic procedure?
17
Please describe the reaction/problems that your pet has experienced with anesthesia in the past:* This field is required.
18
Has your pet taken any medications in the last few days?* This field is required.
YESNO
19
Please list any medications your pet has taken during the last several days and time of last dose. Please include any behavioral medications, herbal supplements, or nutritional products.* This field is required.
20
Please Select
Please Select
Yes
No
Any known allergies to medications
Please Select
Please Select
Yes
No
Any problems with major organ systems?
Please Select
Please Select
Yes
No
Does the patient have a history of seizures?
Please Select
Please Select
Yes
No
Does the patient have or has the patient ever had heartworms?
21
PRE-ANESTHETIC BLOODWORK
Our foremost concern is the well being of your pet. A pre-anesthetic physical exam will be performed prior to the procedure to assess the health of your pet. However, some disorders that might affect your pet’s ability to handle the anesthesia adequately may not be readily apparent without blood screening. If your pet has not had Pre-Anesthetic bloodwork during the last four weeks, we will do the bloodwork before starting the Surgical Procedure.

FLEA MANAGEMENT
We assure our facility is and will remain a flea free environment. Therefore, we require the administration of Capstar (24 hour adulticide in pill form) to all pets dropped off for procedures. An additional cost may be added to the cost of the procedure today.

FLUID THERAPY DURING ANESTHESIA
The administration of intravenous fluids during procedures requiring anesthesia are mandatory. It helps maintain adequate blood pressure and perfusion of the tissues. It also provides easy access for intravenous medications, should an emergency arise. The intravenous setup is placing the indwelling catheter and the use of fluid administration. The area on the forearm will be shaved for placement of the catheter.

PAIN MANAGEMENT
As with all surgical procedures, there is a certain amount of pain involved. Our pet’s experience the same pain and discomfort that we, the owners, experience with similar procedures. To help minimize the discomfort for your pet, we administer an injection for pain prior to surgery, which provides the pain relief for up to 24 hours. Pain management will allow your pet to have a lower level of anesthesia, as well as a more comfortable and faster recovery. Certain surgical procedures may require pain medication for a longer period of time. For your pet’s comfort we offer an extended pain control option.

TATTOO
We tattoo all pets that undergo an ovarian hysterectomy or a castration. We follow the guidelines of tattooing a small mark next to the surgical site that is recognized by animal shelters and other veterinarians. This simple procedure is to prevent your pet, should it be lost in the future, from having to go through exploratory surgery to verify that he/she has been sterilized.

ECG (ELECTROCARDIOGRAM)
ECGs are required for senior patients (7 years +) and patients with pre-existing heart conditions. ECG s detect irregular heart rates, arrhythmias, or enlarged hearts. Additionally, ECGs allow the veterinarian to monitor the effects of drugs and medications administered during the procedure, provides valuable information about the depth of anesthesia your pet is under, and determines the level of pain your pet experiences during surgery so appropriate changes can be made.
22
Non Surgical Options* This field is required.
Please Select
Please Select
My pet already has a microchip
I do not want a microchip placed in my pet.
I elect to have a safe and permanent pet identification microchip placed while under anesthesia. This is to help your pet return to you if he/she is ever lost/stolen. This is the only way to prevent him/her being euthanized should he/she end up in a shelter. Additional cost $54.
Home Again Microchip
Please Select
Please Select
Yes, I need a comfy cone so my pet does not lick at it's incision.
No, I do not need a comfy cone and know that my pet may infect the incision if it licks the incision. If the incision becomes infected, I will have to pay additional fees to fix it.
Comfy Cone
23
In the unlikely event of anesthetic-related cardiac arrest, I ask Stone Ridge Veterinary Medical Center to:* This field is required.
Perform CPR and/or other life-saving measures
Not perform CPR (DNR: DO NOT RESUSCITATE)
24
FELINE LEUKEMIA AND FELINE IMMUNODEFFIEIENCY VIRUS TESTING – CATS ONLY* This field is required.This test is recommended for any new cat and any outdoor cat
I elect to have my cat tested for Feline Leukemia / Feline Immunodeficiency Virus while under anesthesia for $75.
I do not want my cat tested for Feline Leukemia / Feline Immunodeficiency Virus
25
HEARTWORM TESTThis test is recommended for pets over 6 months of age or pets whom have not had a heartworm test within the past year (or have missed a dose in the last 6 months).
I elect to have my pet tested for Heartworms while under anesthesia for $62.
I do not want my pet tested for Heartworms.
26
Vaccines
I understand that if my pet is not up to date on mandatory vaccines that they WILL BE administered today while patient is hospitalized for surgery. I also understand that I am required to pay for these vaccines today, in addition to the all other services performed.
27
List of Mandatory Vaccines:
Cat: FVRCP (1 year) RABIES (1 year)
Dog: DHPP (1 year) Bordetella (at least 1 year) RABIES( 1 or 3 year)
28
DENTAL PROCEDURESYou will be called prior to doing any additional treatments that were not on the estimate.
I understand that if I cannot be reached at the number provided, my pet will be recovered from anesthesia and a second appointment time will have to be scheduled for the additional procedures to be completed.
29
ANESTHESIA / SURGERY / TREATMENT RELEASE
I, the undersigned, do hereby certify that I am the owner and responsible party for the animal that is described above. I consent to and authorize Stone Ridge Veterinary Medical Center Conroe to perform such diagnostic, therapeutic, and surgical procedures as described above. The nature of the procedure has been described to my satisfaction and I realize that no guarantee can ethically or professional be made regarding the results or cure. I realize that while Stone Ridge Veterinary Medical Center Conroe will take every possible precaution to insure the safety of my pet, some risks are involved with anesthesia and surgical procedures. I release Stone Ridge Veterinary Medical Center Conroe from liability in conjunction with any procedures performed on my pet. Also, I authorize Stone Ridge Veterinary Medical Center Conroe, in the event of an emergency to follow through with such procedures as deemed necessary for any medical and surgical complications or unforeseen circumstances that may arise, until further communication can be made with me. Should additional non-emergency procedures be deemed necessary you are unable to contact me for approval, my pet will be allowed to awake from anesthesia and the procedures will be rescheduled for another time. By signing below, I indicate that I have read, understand, and agree to the above information.

FINANCIAL RESPONSIBILITY / POSSESSORY LIEN
I understand that I assume financial responsibility for all services rendered. I further agree to pick up my pet at the designated time and to pay in full all services rendered. I also understand that my pet will not be released until the balance is paid in full. If my pet is not picked up as agreed, a written notice of abandonment will be mailed to me. Twelve days after the notice is issued, my pet will be considered abandoned and may be disposed of in a manner deemed appropriate by Stone Ridge Veterinary Medical Center Conroe. By signing this document, I attest that I have read and agree to the aforementioned conditions.
30
Signature* This field is required.Use your mouse or finger to draw your signature
Clear
Should be Empty: