Willis Animal Clinic
Pre-Anesthesia Questionnaire
Last Name: <client>
Date: <date>
Pet’s Name: <animal>
<animal> will be undergoing general anesthesia for this procedure. There is an inherent risk associated with
anesthesia. Regardless of age, breed, species, or previous anesthetic experiences there is not a 100% guarantee
that <animal> will not have a complication during surgery that could lead to death. However, the Doctors and
Staff at the Willis Animal Clinic take this into consideration and evaluate each patient before, during and after
anesthesia.
Please take a minute to answer the following questions for the doctors so that they can make the
best possible decisions for <animal>. (If you answer YES, please explain)
1. Have you noticed any changes in:
a. Appetite
b. Thirst
c. Energy Level
d. Exercise Tolerance
e. Breathing Pattern
f. Body Condition
2. Has <animal> had any:
a. Diarrhea
b. Vomiting
3. When was the last time <animal> had
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
NO
NO
YES
YES
any food?
We are trying to prevent <animal> from vomiting and inhaling stomach contents during surgery. It will
also lessen nausea in <animal> as <he> regains consciousness.
4. Has <animal> ever had any kind of reaction or problem with anesthesia?
NO
YES
5. Anything else we should know about <animal> before the anesthetic procedure?
6. Medications:
a. Any known allergies to medications
NO
YES
b. List any medications <animal> has taken during the last several days and time of last dose.
Please include any behavioral medications, herbal supplements, or nutritional products.
7. Any problems with major organ systems?
NO
YES
8. Does the patient have a history of seizures?
NO
YES
9. Does the patient have or has the patient ever had heartworms? NO
YES
We do everything we can to make sure <animal> receives high quality care. If for any reason the
doctors feel that anesthesia is not appropriate for <animal> you will be contacted immediately.
ANESTHESIA SURGERY FORM.DOC
REVISED: AUGUST 15, 2011
INITIAL: ______
PRE-ANESTHETIC BLOODWORK
Our foremost concern is the well being of your pet. A pre-anesthetic physical exam will be performed prior to the
procedure to assess the health of your pet. However, some disorders that might affect your pet’s ability to
handle the anesthesia adequately may not be readily apparent without blood screening. If <animal> has not
had Pre-Anesthetic bloodwork during the last four weeks, we will do the bloodwork before starting
the Surgical Procedure.
FLEA MANAGEMENT
The administration of Capstar is required of all hospitalized patients so that we may maintain a flea free
environment. An addition cost of $2.26 to $2.65 in will added to the cost of <animal>’s surgical procedure.
FLUID THERAPY DURING ANESTHESIA
The administration of intravenous fluids during procedures requiring anesthesia are mandatory. It helps maintain
adequate blood pressure and perfusion of the tissues. It also provides easy access for intravenous medications,
should an emergency arise. The intravenous setup is placing the indwelling catheter and the use of fluid
administration. The area on the forearm will be shaved for placement of the catheter.
PAIN MANAGEMENT
As with all surgical procedures, there is a certain amount of pain involved. Our pet’s experience the same pain
and discomfort that we, the owners, experience with similar procedures. To help minimize the discomfort for
<animal>, we administer an injection for pain prior to surgery, which provides the pain relief for up to 24 hours.
Pain management will allow <animal> to have a lower level of anesthesia, as well as a more comfortable and
faster recovery. Certain surgical procedures may require pain medication for a longer period of time. For your
pet’s comfort we offer an extended pain control option.
NON-SURGICAL OPTIONS
Please initial in the space provided to indicate your preference:
HOME AGAIN MICROCHIP
I elect to have a safe and permanent pet identification microchip placed while under
anesthesia for $47.50.
I do not want a microchip placed in my pet.
FELINE LEUKEMIA AND FELINE IMMUNODEFFIEIENCY VIRUS TESTING – CATS ONLY
This test is recommended for any new cat and any outdoor cat
I elect to have my cat tested for Feline Leukemia / Feline Immunodeficiency Virus while
under anesthesia for $32.00.
I do not want my cat tested for Feline Leukemia / Feline Immunodeficiency Virus.
HEARTWORM TEST
This test is recommended for pets over 6 months of age or pets whom have not had a heartworm test within the
past year (or have missed a dose in the last 6 months).
I elect to have my pet tested for Heartworms while under anesthesia for $30.00
I do not want my pet tested for Heartworms.
ANESTHESIA SURGERY FORM.DOC
REVISED: AUGUST 15, 2011
INITIAL: ______
VACCINES
I understand that if my pet is not up to date on mandatory vaccines that they WILL BE
administered today while patient is hospitalized for surgery. I also understand that I am required
to pay for these vaccines today, in addition to the all other services performed.
List of Mandatory Vaccines:
Cat:
FVRCP (1 year)
RABIES (1 year)
Dog: DHPP (1 year)
BB (at least 1 year)
RABIES( 1 or 3 year)
DENTAL PROCEDURES (for retained baby teeth or if a dental procedure is being performed)
I authorize any extractions necessary for <animal>.
Please call prior to doing any extractions. I understand that if I cannot be reached at the
number provided that <animal> will be recovered from anesthesia and a second surgery will
have to be scheduled for extractions to be performed.
ANESTHESIA / SURGERY / TREATMENT RELEASE
I, the undersigned, do hereby certify that I am the owner and responsible party for the animal that is described
above. I consent to and authorize Willis Animal Clinic to perform such diagnostic, therapeutic, and surgical
procedures as described above. The nature of the procedure has been described to my satisfaction and I realize
that no guarantee can ethically or professional be made regarding the results or cure. I realize that while Willis
Animal Clinic will take every possible precaution to insure the safety of my pet, some risks are involved with
anesthesia and surgical procedures. I release Willis Animal Clinic from liability in conjunction with any procedures
performed on my pet. Also, I authorize Willis Animal Clinic, in the event of an emergency to follow through with
such procedures as deemed necessary for any medical and surgical complications or unforeseen circumstances
that may arise, until further communication can be made with me. Should additional non-emergency procedures
be deemed necessary you are unable to contact me for approval, my pet will be allowed to awake from
anesthesia and the procedures will be rescheduled for another time. By signing below, I indicate that I have
read, understand, and agree to the above information.
FINANCIAL RESPONSIBILITY / POSSESSORY LIEN
I understand that I assume financial responsibility for all services rendered. I further agree to pick up my pet at
the designated time and to pay in full all services rendered. I also understand that my pet will not be released
until the balance is paid in full. If my pet is not picked up as agreed, a written notice of abandonment will be
mailed to me. Twelve days after the notice is issued, my pet will be considered abandoned and may be disposed
of in a manner deemed appropriate by Willis Animal Clinic. By signing this document, I attest that I have read
and agree to the aforementioned conditions.
Signature of Owner and Responsible Party
ANESTHESIA SURGERY FORM.DOC
Date
REVISED: AUGUST 15, 2011
Signature of Witness
INITIAL: ______