About you Your first and last name (including any other surname your pet may be under) Your Address Your Phone number Have you received an estimate? Yes or No. If no, we will email you an estimate prior to the day of the procedure. Yes (I have an estimate), No (please send me an estimate) Email address (all discharge instructions will be sent to this address, please make sure firstname.lastname@example.org is placed as a contact) About your pet Pet's name What procedure is your pet having today Additional Procedures Are they any other procedures you would like done? For example, nail clips, check ears? Let us know. These may incurr an extra fee. If not in the estimate, We have 3 tier blood tests (Miniprep incl PCV,TS, Glucose, urea, Urinesg cost -free, Prep (7 chem + full hematology ($125), Comprehensive(12 chem + full haematology) $170. Specify Prep or Comprehensive. If not in the estimate, we do recommend all surgical procedures go onto intravenous fluids for extra support (Ketamine CRI) Cost $90.00 Yes or No Time last fed Is your pet on any medications, supplements or treatments in the past seven days. Yes/No - if yes, what are they Surgery consent questions (Yes/No) Has your pet ever had a past anaesthetic event that you thought went poorly? Yes/No Has there been any.... (Yes/No) - if yes, please tell us more Vomiting Yes/No Coughing Yes/No Trouble breathing Yes/No Diarrhea Yes/No Fits/Epilepsy/Unusual Turns Yes/No Allergies/Reactions to medications? Yes/No Illness/Injury in the past 30 days? Yes/No Anything that may affect the anaesthetic or your pet's recovery from the procedure recommended? Change in appetite Yes/No Change in the amount they drink Yes/No General Health questions Is your pet current on.... Heartworm prevention? If so, what do you use Flea/Tick Control? If so, what do you use and when was it last given Vaccinations? Do you anticipate that there will be any problems keeping your pet reasonably quiet during recovery? Yes/ No. Any special requests for sedation or e collars can be made here. Consent for CPR If there is an adverse event, if we are unable to contact you within 20 minutes after initiating CPR, or if after exercising reasonable medical judgement that there is no hope for success, the staff will cease further CPR. Please perform CPR - Yes (fees apply) No Final consent I consent for my pet to be admitted to hospital for the above procedure, and I submit this form stating that I am comfortable with the information that has been given to me about the risks associated with the proposed treatment or surgical plan.