Anesthetic Procedure Drop-off Form

Anesthetic Procedure Drop-off Form

Redwood Pet Clinic
Name*

Client Full NamePet's Name
Date*

MonthDayYear
Date
1. What procedure is your pet here for today?
2. When was the last time your pet ate?
3. Do you feel your pet is in good general health?

YesNo
3a. If you answered "no", please explain:
4. Has your pet had any problems with anesthesia in the past?

YesNo
4a. If you answered "yes", please explain the experience your pet endured.
5. Are you planning to leave any personal items with your pet today?

YesNo
5a. If you answered "yes", please list the items you plan to leave with your pet.
6. Is your pet on any medications?

YesNo
6a. If you answered "yes", please list the name(s) of the medication(s), dosage, frequency, and last time given.
7. Please leave a reliable phone number where you or an authorized representative (include name) can be reached during the procedure.
8. Is your pet microchipped?

YesNoUnsure
8a. If you answered, "no" would you like us to microchip your pet? If you're unsure or would like more information, please select option 3 below.

YesNoPlease give me more information
All accounts are to be paid at the time of pick-up. If you, the pet owner, are not the person picking up your pet, do you authorize someone else to do so?
Yes No

If so, please provide the person's name: Authorized person

If this person is not financially responsible for your pet, please arrange for payment ahead of time.
Thank you!
REDWOOD PET CLINIC STATEMENT:

Please understand that during your pet's stay with us, unforeseen conditions may arise that necessitate medical attention from our staff. If we are unable to reach you or your representative(s) at any of the above phone number(s), your signature on this form authorizes the performance of such procedures as are deemed necessary by the Veterinarian's professional judgment.

I also authorize the use of appropriate anesthetics and other medications as deemed necessary by the Veterinarian. I have been advised as to the nature of the procedure(s) and risks involved with general anesthesia.
Signature of Owner or Authorized Representative

Clear
Should be Empty: