Client Name *

First

Last

Patient Name *

Email *

Phone number at which owner can be reached at *

What time/when did the pet LAST EAT/how much? *

Meds & supplements? Last dose given? Current/previous medical conditions/problems/diagnoses that may affect anesthesia? *

To your knowledge, does your pet have a heart murmur? *

If your pet is found to have a heart murmur, would you like us to proceed with the procedure?

Known allergies or allergic reactions? *

Previous anesthesia or surgery? *

–If yes, which procedure(s)? –How did pet do with anesthesia/recovery?

Does your pet have or recently had any of the following symptoms?

Change in attitude or activity level (ie: listless/lethargic/withdrawn)?
Decreased or complete appetite loss?
Increased water consumption?
Unexplained weight change (gain, loss, or distension of the belly)?
Coughing, sneezing, wheezing, hacking, nasal discharge or difficulty breathing (acting as if they have a cold)?
Vomiting? How frequently? Last episode? Still eating/interested in eating? Diarrhea/loose stools? How frequently? Last episode? Any blood, mucus, or tarry/black foul smelling stool present?

Please explain any of the marked checkboxes above

Please check all that appy to your pet

Pre-Anesthesia Spay/Neuter Form

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