Surgery Admission & Consent Forms

Client Name:*

Pet's Name:*

Date of Procedure*

Date

We offer these pre-anesthetic blood panels, to evaluate your pet's internal health prior to anesthesia **Senior Pets (7 years and older) are required to have a minimum of Panel #1**

My wishes for pre-anesthetic diagnostics today: **Senior Pets (7 years and older) are required to have a minimum of Panel #1***

PCV (packed cell volume)/ TP (total protein)Basic Panel: Chem 15, SDMA, CBCPremium Panel: Chem 15, SDMA, CBC, T4I decline a pre-anesthetic blood panel because: My pet is under 7 years of age. I understand that this prevents the doctor from being able to determine any underlying illnesses that could adjust the anesthesia or surgery planI decline a pre-anesthetic blood panel because: Previously done within past 3 months

CATS ONLY - This test is important for all cats that have not been tested recently, especially new introductions to the family

Triple Test: Feline Leukemia Virus, FIV, and Heartworm blood test

DOGS ONLY - Please be aware that Heartworm blood test is required to be up to date (within the last year) for all dogs over 9 months of age

**I hereby consent and authorize the doctors and staff of Log Cabin Animal Hospital to perform on my pet sedation and/or general anesthesia, plus the following surgical procedures and services:*

"Dental" COHAT (Comprehensive Oral Health Assessment & Treatment)Surgical Sterilization (spay or neuter)Mass RemovalOther

**I hereby consent and authorize the doctors and staff of Log Cabin Animal Hospital to perform on my pet sedation and/or general anesthesia, plus the following surgical procedures and services:*

Surgical Sterilization (spay or neuter)Mass Removal"Dental" COHAT (Comprehensive Oral Health Assessment & Treatment)Other

If my pet requires teeth to be extracted, my wishes are*

Choose one option

Advance Directive- Should my pet develop cardiac or respiratory failure while under the care of the staff and doctors at Log Cabin Animal Hospital, my wishes are (please be aware that CPR success rate for anesthetic related arrest is about 50%):*

Perform emergency life saving treatments cardiopulmonary resusitation CPR as the doctor feels appropriate- I agree to pay for this additional care (costs range from $30-300)Do not perform any life saving treatments ("Do Not Resuscitate")

Any special concerns you have about your pet today? Any signs of illness noted?*

When did pet last eat?*

Dogs and cats please fast about 4-6hours; for rabbits, do not fast. All pets may have free access to water!

Has your pet been given any medications within the past 7 days? If yes, please list (name, dose, amount, when last given):*

Please continue to give all medications as usual, including the morning of surgery, unless directed otherwise. For orthopedic surgeries (joints/knees) do not give the NSAID pain medication for 3 days prior)

Heartworm Prevention Type*

Date last given/applied:

Date

How many do you need refilled today to continue year round? (# doses)*

Flea/Tick Prevention Type*

Date Last Given/ Applied*

Date

How many do you need refilled today to continue year round? (# doses)*

For intact females- if known, when was your pet's last heat cycle?

Are you interested in having a microchip (permanent ID) placed in your pet? It would add additional $54*

Additional Services requested today?

Anything else you would like the doctor/staff to know before today's procedure?

Primary Contact Information for surgery day*

Area CodePhone Number

Please check here if you do NOT wish to be texted with updates about your pet today

No text - I prefer phone calls

**No personal items from home can be left with us due to the Coronavirus pandemic. Please take your carriers home as well.

Pre-Anesthesia / Surgical Admission Questions