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 & dosagesDoes your pet have any allergies or dietary requirements?*If answered yes, please list all allergies or dietary requirementsDoes your pet have any underlying medical conditions?*If answered yes, please list all medical conditionsWould 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 £104.50, further information about this can be found on your pre-operative information sheet.* Yes No I would like to discuss further during my pet’s admission appointment 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 £130, further information about this can be found on your pre-operative information sheet.* Yes No I would like to discuss further during my pet’s admission appointment Would you like your pet to be microchipped? This is an additional cost of £37.20.*If your pet is having a surgical procedure, they will need to be prevented from interfering with their wound. Buster collars are included as standard with your pet's procedure but you can upgrade to a medical t-shirt. The medical t-shirt is similar to a baby grow, your pet can wear this at all times and it is often tolerated better than a traditional buster collar. Medical t-shirts aren't suitable for patients undergoing surgery on their head or legs and they are also not suitable for cat castrations. Please indicate your preference below: Buster collar Medical shirt (from £18.50 depending on size) My pet is not having a surgical procedure. We recommend that 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 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: 1 tin of Royal Canin Gastrointestinal Wet Food – £4.75 and for cats: 2 sachets of Royal Canin Gastrointestinal Wet Food – £3.20* Yes – I would like to take food for my pet’s recovery No – I will prepare a bland diet for my pet’s recovery Will you be claiming for your pet's procedure through pet insurance? Yes No Insurance information – please note that it is practice policy for insured clients to pay for their pet's procedure on collection of their pet and then claim this back through their insurance company. In some circumstances, we may be able to offer a direct claim where the insurance company pays the practice directly, this is dependent on a number of factors. Direct claims MUST be authorised in advance of your pet's procedure as we will need to make several checks on your insurance policy to confirm we can offer this. If you need to discuss this further, please call the practice on 01606 592714. Please note there is a £25 admin charge for direct claims with a continuation fee of £5.20 for each subsequent claim related to the same condition. In all cases a completed insurance claim form should be submitted on collection of your pet so we can process this for you.* Please tick to confirm you have read and understood our insurance process Below are several standard statements regarding patient procedures, please read through these and select each statement 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 anaesthetic drugs does involve some risk. This could include but is not limited to: low blood pressure, low body temperature and in rare cases can cause death.* I understandI 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 understandI 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 (rabbits and guinea pigs) where there is not a licensed veterinary product available for that species, we may use a veterinary product that is licensed for a different species such as canine and feline drugs.* I understandI 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 that the practice will perform any procedures necessary in the interest of my pet's safety.* I understandFOR DENTAL PROCEDURES ONLY – I understand that my pet's teeth will be assessed fully once they are under anaesthetic and any extractions will be made as required. If you are concerned about teeth being extracted and would like to be contacted after the vet has assessed the teeth fully – please make this clear during your admit appointment. I understandI understand that the full fee for my pet's procedure will be payable when my pet is discharged.* I understandI 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 usedDoes 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?Consent I agree to the privacy policy.CAPTCHA Submit Enable cookies to show the form. Manage my cookie choices
