Surgery/Sedation Admissions Questionnaire

Surgery/Sedation Admissions Questionnaire

Please return at least 24 hours prior to your appointment time
Owner's Name *

First Name Last Name
Pets Name
Please take a few minutes to fill out this form completely. This will help us to better understand our patient and, in turn, help provide for the best possible anesthesia planning and care.
Will your pet be fasting at least 12 hours prior to surgery check in? (Ensure your pet does not eat 12 hours prior to surgery) *
Has your pet been given any medications or treatments in the last 7 days? (if yes, please list them) *
Has your pet had any previous problems following an anesthetic procedure? *
Has your pet ever had reactions to any drugs in the past? *
Does your pet suffer from separation anxiety when away from home? *
Has your pet had a history of licking or chewing at surgical incisions? *
Do you anticipate there will be any problems keeping your pet in a clean, dry area during recovery at home? *
Do you anticipate there will be any problems keeping your pet reasonably quiet during recovery? *
Do you have any additional information about your pet that we should know? *
Are you available to pick-up your pet after the procedure before 6 pm? (if no, please talk to your doctor prior to surgery) *
Have you received an estimate for services? *
Do you have any questions for the surgeon? *
What is the best number to reach you at while your pet is at FCVH *
Signature: *

Clear
Date *

Month Day Year
Should be Empty: