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Anesthesia Procedure Form
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Anesthesia Procedure Form
Save time during your next appointment! Complete your Anesthesia Procedure Form online from any device at any time before your visit.
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Client Information
Name
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First
Last
Email
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Phone
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Address
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Address Line 1
Address Line 2
City
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State
Zip Code
Pet Information
Pet's Name
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Pet's Birth Date/Age
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Species
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Breed
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Color
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Weight
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Sex
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Male
Male Neutered
Female
Female Spayed
Reason for Anesthesia/Sedation
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Additional Preventive Care and Services for Your Pet:
Would you like any other services performed while your pet is with us today?
Pre-medication prior to vaccinations:
We take every step possible to minimize the chance of allergic reactions to vaccines. While the chances of a reaction are low, there is always a risk for your pet to react even if they have had no prior history or symptoms of vaccine reaction. Ask us about risk level. We recommend diphenhydramine injection prior to vaccinations to minimize the chance of reactions or lessen the severity of the reaction if they have one. Post vaccination pain medications are also available if you’d like.
Heartworm Prevention:
Heartworm disease is caused by a worm that can grow and live in the heart and nearby blood vessels of the lungs in infected pets. These parasites are transmitted by mosquitos and can cause substantial damage to the heart and lungs. We can prevent this with an annual injection (Pro-Heart) or monthly oral medications (Interceptor Plus). A heartworm test is recommended prior to administering prevention.
Flea and Tick Prevention:
Parasites carry many diseases and can cause health issues with pets and people. We recommend Credelio or Bravecto year-round to prevent flea infestations.
Microchip:
This radio transmitter technology helps identify if they become lost or stolen and can increase the chance of you being reunited.
Nail Trim:
Long nails lead to discomfort for your pet as well as lead to damage of your home or property. If you would like for us to trim your pets nails today, we would be happy to do so.
Anal Gland Expression:
These glands are found along the edge of the anus and contain foul smelling liquid. They normally empty during a bowel movement but some dogs who are scooting, licking, or chewing at their rectum may have blocked glands and need to be expressed manually.
Ear cleaning:
Routine ear cleanings can help prevent and reduce wax build up that may lead to ear infections.
Bladder Ultrasound scan:
Bladder inflammation is a very common problem associated with urinary disease. Bladder inflammation and other structural abnormalities such as stones, cancer, and polyps may be visualized during this scan and is important with every urinalysis
Do you need any skin and dental care products?
Shampoo
Conditioner
Ear Cleaner
Dental Chews
Toothbrush Kit
The doctor, and/or you, the client, have determined that your pet requires sedation and/or anesthesia for the above procedure. Any use of sedation or anesthesia carries inherent risks. The veterinary staff of vetXpress will take utmost care to avoid any complications, but such complications cannot always be foreseen. For pets that require sedation and or anesthesia for procedures over the age of six, vetXpress highly recommends pre-operative bloodwork and Intravenous fluids. The pre-operative blood work will assess internal organ functions. Intravenous fluids helps to keep your pet’s blood pressure stable, ensuring that oxygen and nutrients continue to reach the vital organs
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I have read and understand
Pre-Operative blood screening
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Approve
Decline
Fluid Therapy
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Approve
Decline
I understand the risks of sedation/anesthesia and will not hold vetXpress responsible for any unforeseen complications. I authorize vetXpress and its veterinarians to perform sedation/anesthesia on my pet. I understand that additional charges may be incurred in the event of any complications.
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I have read and understand
In the event of a medical emergency, the veterinarian will administer appropriate medical care as elected below:
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In the event I cannot be reached, please perform all emergency, non-elective treatments, and necessary diagnostics the doctor deems necessary for the best care of my pet until someone can be reached.
Do not administer any emergency medical treatment until specific authorization is given (excluding basic CPR).
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