Anesthetic Form

Day of Sedation: *

Date

Name *

First Name Last Name

Email *

example@example.com

Phone Number *

This must be the best number to reach you at regarding your cat.

Which would you prefer for updates and communications about your cat? *

Call Text Email

Procedure to be Performed: *

Did you keep your cat off food and water for at least 12 hours? *

Yes No

Is your cat on any medications? *

Yes No

If Yes, please explain:

When was flea and tick prevention last given and what type?

Our kennel has a "NO FLEAS AND TICKS" policy. If your cat is examined and found to have fleas or ticks, they will be treated at an additional cost.

Has your cat seemed healthy to you? *

Yes No

If No, please explain:

Recommended for ALL ages, especially senior cats (10 years +). We recommend performing a pre-surgical screening (lab tests to evaluate the liver and kidneys) BEFORE using any anesthetic (unless these test were done in the last 30 days). These tests allow us to see "inside" your cat and make informed decisions about the best way to treat him/her medically. Do we have permission for these OPTIONAL tests? Cost is ~$69.30 *

Yes No

While your cat is sedated, would you like us to perform any of the following procedures at an additional cost?

Home Again Microchip Placement ($44.95) Pedicure (No Charge) Shave rear ($11.60 and up, plus tax) Shave matts ($11.60 and up, plus tax)

Please note: Pain medication (both injection and take home) is at the doctors discretion for ALL procedures. REMEMBER this is already included on all spay procedures! However, this is not required or included for neuters only, if your male cat is just getting a neuter procedure, would you like to have pain medication sent home after surgery? This is a transdermal pain medication and is applied to the ear flap, the cost is $23.00 *

Yes No

List person, other than you, authorized to pick up your cat:

First Name Last Name

Signature

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