Pre-Anesthetic Form

Name *

First Name Last Name

Pet's Name *

Phone Number *

Area Code Phone Number

E-mail *

How would you prefer to be contacted after the procedure is completed.

Phone Text I will not be available by phone.

Has the medical health of your pet changed since the procedure was scheduled?

No Yes

If yes, please list details.

A thorough exam will be done on your pet the morning of anesthesia, but many conditions cannot be diagnosed with the examination. We recommend appropriate blood tests to screen for internal problems that we cannot detect on the physical exam. Your pet can’t tell us what might be wrong, so our doctors will use your pet’s blood work to get a clear picture of what is going on beneath the surface. These tests identify pre-existing conditions thus improving anesthetic safety, and also provide valuable baseline data for future comparison.

There is an excellent video from the American Veterinary Medical Association on the importance of blood test for wellness exams, sick pets and pre-anesthetic testing.

Link to AVMA video

You are welcome to visit our website to learn more about pain control and anesthesia safety.

CPAH offers 3 levels of health screening. Each level provides appropriate information depending on the age of your pet.

Junior Pre-Anesthetic Health Screen (1-2 years) $68

Adult Pre-Anesthetic Health Screen (3-7 years) $88

Golden Pre-Anesthetic Health Screen (over 7 years) $138

Please perform the health screen for my pet.

Yes No

You can also have your pet permanently identified with the Microfinder® Microchip. This chip has a code that will be unique to your pet. The cost of the microchip is $81

Please microchip my pet.

Yes No

Your pet can be fed the night before the procedure. Water is OK the morning of the procedure.

When you arrive at our hospital, one of our technicians will discuss the procedure and answer any questions you might have.

E-Signature -- You can use your mobile device, mouse or touch screen device to sign this document.

Clear

Clinton Parkway Animal Hospital Pre-Anesthesia Form