North Ridge Veterinary Hospital 6336 N. Ridge Rd. Madison, Ohio 44057 (440)428-5166
Patient Name:_________________Age:______Sex:_____Owner Name:___________________Date:________
Pre anesthetic screening is a critical part of safer anesthesia. It allows us to identify patients with increased surgical risk and may change our anesthetic protocols and surgical techniques based on your pet’s health assessments. We strongly recommend that you screen your pet prior to surgery. Certain breeds of animals with liver, kidney or other long term illnesses must be evaluated.
Surgical Information Form
Please fill out the following:
1. Has your pet had food or water in the past 12 hours? Yes___No___. If Yes, please explain.
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2. Have your noticed any change in your pet’s water consumption or urinary habit? Yes___No___. If Yes, please explain. __________________________________________________________________________
3. Has your pet ever suffered a trauma such as being hit by a car, shot or injured? Yes___No___. If Yes, please explain.___________________________________________________________________________
4. Does your pet have any allergies to medications or vaccinations? Yes___No___ If Yes, please explain_____
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5. When was your pet’s last heartworm test? Month______Year______ Is your pet on heartworm preventative? Yes____No____. If yes, how often is preventative given?____________________________
6. Is there any reason you believe your pet would be a poor surgical risk? Yes___No___ If Yes, please explain
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7. Please list ALL medications your pet is taking (please include heartworm preventative)________________
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8. Does your pet suffer from diabetes, seizures, or bleeding disorders? Yes___No___ If Yes, please explain
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9. Is your pet microchipped? Yes___No___ Would you like to microchip your pet at this time? Yes___No___
The cost of a microchip is $70.00
10. May your pet have a blanket or comforter in a cage or run while staying in the hospital? Yes___No___
___A-Opt A RECOMMENDED (DG36)
Complete Anesthetic screen-complete blood count, chest x-ray and biochemical organ testing $169.00
___B-Opt B (DG37)
Complete blood count, kidney and blood glucose, and chest x-ray $143.00
___C-Opt C (DG38)
Complete blood count, kidney and blood glucose $76.00
___Opt. ADD ON 1: (I324)
Coagulation panel this option will check to see if you pet has any clotting disorders. $95.00
___Opt. ADD ON 2: (MS30)
Electrocardiogram $92.00
___ Laser Treatment: This treatment is done immediately after the surgery and is an effective way to help
. control inflammation and pain. $51.00.
___OPT D: I decline all pre-surgical screening for my pet and will assume any addition risk to my pet. Please select a pre-surgical test or ask our staff to explain your options. If no selection is indicated, we will do OPTA at your expense.
Please leave a phone number where we can reach you the day of the surgery____________________.
Please be available at one of these numbers (alternative phone#)________________. Thank you
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