Pre-Anesthetic Form

Name*

First NameLast Name

Pet's Name*

Phone Number*

Area CodePhone Number

E-mail*

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

PhoneTextI will not be available by phone.

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

NoYes

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) $88

Adult Pre-Anesthetic Health Screen (3-7 years) $114

Golden Pre-Anesthetic Health Screen (over 7 years) $175

Email

example@example.com

Please perform the health screen for my pet.*

YesNo

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 $99.00

Please microchip my pet.

YesNo

If yes, please list email address for microchip registration.

example@example.com

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

By signing below you authorize Clinton Parkway Animal Hospital and its staff to perform the anesthesia.

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

Clinton Parkway Animal Hospital Pre-Anesthesia Form