Client Name *

First

Last

Email *

Phone Number *

Patient Profile

Pet's Name *

Breed *

Weight *

DOB *

Species *

Dog
Cat

Sex *

Male
Neutered Male
Female
Spayed Female

Have you seen any fleas or ticks on your pet or any parasites in their stool?

Yes
No

Please help us provide the best care for your pet by responding to the following questions prior to their scheduled appointment. Thank you.

Your pet has their surgical procedure scheduled soon. We want this day to be as easy as possible for you. Here are a few things to know going into the big day:

Please, no food after 10:00 pm the night before surgery. If your pet is on any maintenance medications, these are OK to give. Please let us know at check in if any medications have been given.
Prior to the appointment, please be sure to complete the anesthesia consent form.
We will continue to communicate with you through PetDesk (this platform) before, during and after the procedure. You may text us with any questions you may have after your pet's surgery discharge.

Thank you for reading through this message and for trusting us with your pet's care.

Have/will you withhold food from your pet for 8 to 2 hours prior to drop off time

Yes
No
I'm not sure

What supplements, OTC medications and/or prescription medications does your pet receive? (You can also take pictures and send them in this chat after completing this form)

What procedure/surgery is your pet scheduled for? (please select all that apply)

Have you reviewed and approved the treatment plan/healthcare plan for your pet's procedure and understand that you are responsible for payment in full upon discharge?

I have not reviewed the healthcare plan, nor do I have questions. I need to speak to the veterinarian or technician more before my pet undergoes this procedure
Yes, I have reviewed the healthcare plan and consent to this procedure

For dental procedures only: Extractions of diseased teeth may be necessary. These are charged per tooth and will be in addition to your proposed treatment plan. Recommendations are made during the veterinarian's oral exam while your pet is under anesthesia. If extractions are recommended, we will make every effort to reach you prior to performing extractions. If we cannot reach you to discuss why we are recommending extractions and added cost, how would you like us to proceed?

If I cannot be reached, perform the recommended extractions.
If I cannot be reached, DO NOT perform the recommended extractions

If your pet has not had routine bloodwork performed in the last month, we recommend having it done the morning of your pet's procedure. We highly recommend this for patients over the age of 7 years, but it can be beneficial for pets of any age.

Yes, please perform a chemistry panel and complete the blood count.
I'm unsure if my pet has had bloodwork performed recently; please let me know if bloodwork is recommended.
No, I do not wish to have bloodwork performed on the morning of the procedure

If your pet's procedure requires a surgical incision or wound care, would you like us to treat the area with cold laser therapy? Laser therapy promotes endorphin release, vasodilation (which increases blood flow to bring in oxygen and cells involved in the healing process), muscle relaxation, decreased inflammation, and faster healing and repair. Please see your treatment plan for the fee for this service.

Yes, please treat the surgical area with cold laser therapy
No, do not treat with cold laser therapy

Does your pet need any additional services while with us today? (please select all that apply)

Microchip Placement
Anal Gland Expression
Ear Cleaning
Nail Trim

Although not anticipated, should unexpected life-saving emergency care be required, which of the following life saving measures would you like the hospital staff to attempt?

CPR - Cardiopulmonary Resuscitation
DNR - Do not attempt Resuscitation

Complications can occur, and we do our best to minimize the risks for patients. The most serious or common complications include Unexpected anesthesia reaction, unexpected bleeding disorder, slow recovery, surgical site pain, and/or surgical site reaction.

As with any procedure requiring general and/or local anesthesia, there are certain risks that serious complications or even death may result. To minimize the risk of such occurrences, we recommend baseline bloodwork be performed in order to assure proper organ function, clotting ability, detect anemia or infection, baseline for future reference.

The complete blood count (CBC) is a more sensitive indicator of disease than the physical exam. Additionally, white blood cells (WBCs) and platelets can change within hours due to acute infectious diseases. Abnormal glucose levels can increase anesthetic risk and differ markedly between fasted and non-fasted samples, breeds, ages, and sick and healthy patients.

Evaluating electrolytes hematocit and total protein in fasted patients is essential for monitoring during anesthesia, minimizing the risk of arrhythmias and hypotension and facilitating patient recovery.

As the owner of the above named pet, I certify that I am over the age of 18; and I authorize the staff of this hospital to perform the procedure(s) listed above, as well as those deemed necessary to treat life threatening emergencies.

As with all anesthetic, treatment and/or surgical procedures, I understand there are risks inherent in these services. I acknowledge that staff members at this practice have explained the procedures to me, answered questions to my satisfaction and cannot be held responsible for any unforeseeable results. Further, I understand that I am financially responsible for all costs incurred during this surgery, treatment, and hospitalization and that payment is due at the time of discharge.

While I accept that all procedures will be performed to the best of the abilities of the staff at this facility, I understand that veterinary medicine is not an exact science and that no guarantees have been made regarding the outcome of this/these procedures. I have read and understand the nature of the above procedures and accept the specific terms and conditions set forth herein.

Patient Procedure Consent *

I agree with the statement above

What phone number will be the best to contact you the day of your pet's procedure? *

Please sign your name to verify you have read and completed the above form. *

Clear Signature

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Anesthesia Consent Form

Anesthesia Consent Form

Patient Profile

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We proudly serve the pets of Austin, TX and beyond!

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