Anesthetic Procedure Check-In
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Email address *
Client First Name *
Your answer
Client Last Name *
Your answer
Patient Name *
Your answer
Client Information
To ensure the best care and communication for your pet, please provide up-to-date information below.
Confirm Home Address
This should be the address at which your pet spends the majority of its time, as it will be on your pet's rabies certificate and is required for Brazos County License/Tag registration.
Street/Apartment Number *
Your answer
City, State (format "City, ST") *
Your answer
5-Digit Zip Code *
Your answer
Confirm client driver's license number & state issued
Your answer
Confirm client date of birth *
MM
/
DD
/
YYYY
Contact Information
Primary Contact *
Please provide a phone number where you will be readily reachable during your pet's stay with us. (###-###-####)
Your answer
Alternate Contact
If you cannot be reached at your primary contact number, is there another number you would like us to try? (###-###-####)
Your answer
How would you prefer to be contacted while your pet is with us? *
Please select your primary concern: *
Patient Medication History
What monthly heartworm preventative do you use for your pet? *
What flea preventative do you use for your pet? *
Please list all OVER-THE-COUNTER medications and supplements you give your pet, their dosages, and how frequently they are administered. *
Your answer
Please list all PRESCRIPTION medications you give your pet, their dosages, and how frequently they are administered. *
Your answer
Do you need refills of any medications? Please list names and quantities.
Your answer
Recent Patient History
Please answer questions based on the past 2 to 4 weeks of your pet's behavior.
Has your pet recently had any of the following problems? *
Check all which apply
Required
For the following questions, please select a number based on the following scale:
1-"Significantly Decreased", 2-"Decreased", 3-"Normal/Has Not Changed", 4-"Increased", 5-"Significantly Increased"
Appetite Level *
Significantly Decreased
Significantly Increased
Water Intake *
Significantly Decreased
Significantly Increased
Activity Level *
Significantly Decreased
Significantly Increased
Frequency of Urination *
Significantly Decreased
Significantly Increased
Patient's Home Environment
Is your pet primarily... *
Does your pet regularly visit any of these areas? *
Check all which apply.
Required
What diet (brand, primary protein) do you feed your pet? *
Your answer
How frequently do you feed? *
What quantity do you feed at each meal? *
Please use Cups as a standard measurement. If you are unsure of the exact quantity, give your best approximation.
Your answer
Do you feed any treats? *
Please list the type/brand if possible.
Your answer
Additional Service Requests
If you would like any additional services to be provided while your pet is with us, please check below:
Additional costs apply. Please note that due to the potential for a dangerous drop in body temperature during anesthesia and deterioration of incision sites, we are unable to bathe a pet on the day they undergo surgery or anesthesia.
It is vital to your pet's anesthetic safety that no food is provided after 9:00 PM the night prior to admission. Water may be provided overnight, but should be removed first thing in the morning. *
Does your pet allow you to administer medications at home? *
If medication is dispensed, what form do you prefer? *
Check all which apply
Required
Would you like to run a blood chemistry panel prior to surgery? *
Pre-anesthetic blood work helps the doctors ensure there is no metabolic reason your pet should not undergo surgery. Examples may include but are not limited to: congenital liver shunts, kidney disease, etc.
Would you like to have your pet microchipped? *
A microchip is a permanent form of identification implanted beneath the skin.
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