Pre-Anaesthetic Patient Questionnaire What is your surname?* What is your pets name?* Please provide a telephone number for us to contact you on. We must be able to contact you on this number throughout the day and in case of an emergency.*Is your pet up to date with their vaccinations?* Yes No Is your pet currently on any medications?* Yes No If answered yes, please list the medications & dosages Does your pet have any allergies or dietary requirements?* If answered yes, please list all allergies or dietary requirements Does your pet have any underlying medical conditions?* If answered yes, please list all medical conditions Would you like your pet to have a pre-operative blood test? This test is offered as an option to all canine and feline patients having an anaesthetic but is highly advisable for senior patients and patients having long anaesthetics. The blood test is done on the morning of surgery and then analysed in our house lab. This is an additional charge of £85.00, further information about this can be found on your pre-operative information sheet.* Yes No Discuss Options Would you like your pet to have fluid therapy during their procedure? This is an optional extra for all canine and feline patients. Fluid therapy helps support the liver and kidneys to process anaesthetic drugs and also assists in maintaining blood pressure. This is an additional charge of approximately £115.40, further information about this can be found on your pre-operative information sheet.* Yes No Discuss Options Would you like your pet to be microchipped? This is an additional cost of £35.43.* If your pet is having a surgical procedure, they will need to be prevented from interfering with the their wound. Buster collars are charged at £7.85, or you can opt for a medical t-shirt which is £24.60. A medical t-shirt is similar to a baby grow, your pet can wear this at all times and is often tolerated better than a traditional buster collar. Medical t-shirts aren't suitable for patients undergoing surgery on their head or legs as these areas would not be covered by the shirt. Please indicate your preference below.* We recommend your pet is fed a bland diet following their anaesthetic or sedation. This could be something you choose to prepare like white fish, chicken or scrambled egg. Alternatively, we stock a bland diet that is designed for recovering patients – this is highly palatable and balanced to provide all the nutrients they need in the first few days of recovery. For Dogs: 3 tins of Royal Canin Gastrointestinal Wet Food: £14.01, and for cats: 3 sachets of Royal Canin Gastrointestinal Wet Food: £4.68.* Will you be claiming for your pet's procedure through pet insurance?* Insurance company name Policy number Policy excess and any other informationPlease read the statement and check here to confirm you understand:* I understand that whilst my pet will be closely monitored during their anaesthetic and all efforts are taken to minimise risks, the use of an anaesthetic drug does involve some risk to my pet. I understand that whilst every care and attention will be given to my pet, surgical procedures involve some risk. This could include, but is not limited to: bleeding, infection and wound breakdown. I understand that off license drugs may be used on my pet. This means that a human version of a drug may be used if a licensed veterinary drug is not available. Alternatively, this may also mean that in the case of exotic pets (including rabbits and guinea pigs) where these is not a licensed veterinary product for that species, we may use a veterinary product that is licensed for a different species such as canine and feline drugs. I understand that in the event of complications, every effort will be taken to contact me on the numbers I have provided, I agree to be contactable at all times. If I am unavailable, then I understand the practice will perform any procedures necessary in the interest of my pet’s safety. I understand that the full fee for my pet’s procedure will be payable when my pet is discharged.I confirm I have read the following:* IMPORTANT INFORMATION: Please remember that your dog or cat should be starved from 10pm the night before their procedure and ensure that they have no breakfast in the morning. Water can remain down at all times. For cats, please keep them indoors overnight so they don’t catch their own breakfast! Rabbits and Guinea Pigs – these animals are different to dogs and cats and DO NOT REQUIRE STARVING prior to an anaesthetic. Ensure they have food available as normal. It would be helpful if you could bring a selection of their favourite foods on the day to encourages them to eat after their procedure.Please select species below:* Dog Cat Rabbit What does your dog normally eat and drink? Where does your dog prefer to toilet? Please give details of the command used Does your pet have any dislikes e.g. types of food, other animals, men/women? Is there any additional information you would like to tell us about your pet? What does your cat normally eat and drink? Where does your cat go to the toilet? What does your rabbit normally eat? Does your rabbit drink from a bowl or a water bottle? Does your rabbit drink from a bowl or a water bottle? CAPTCHA Submit
