Feline Neuter - Pre-Surgical Medical Questionnaire

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For a faster check-in process, please answer the following questions before your pets' appointment.
Your check-in process may be prolonged if this form is not completed ahead of time.

If the following feeding guidelines are not followed correctly it is possible your appointment may be to rescheduled.
Feeding guidelines for pets UNDER a year old: - Patients must eat a FULL meal the night before their procedure between the hours of 6:00 pm - midnight and then must eat a FULL meal the morning of their procedure between the hours of 5:00 am - 6:30 am.
Do not restrict water intake. ***RISKS of not following this guideline is that your pet could develop hypoglycemia (low blood sugar) due to puppies/kittens having a harder time regulating their blood sugar. This can make their surgical procedure a higher risk.Feeding guidelines for pets OVER a year old: - Patients must eat a FULL meal the night before their procedure between the hours of 6:00 pm - midnight and then fast the morning of their procedure. Do not restrict water intake. ***RISKS of not following this guideline is that your pet could be at risk of aspiration pneumonia

Has your pet ever had any adverse reactions to medications, vaccinations, or anesthesia?

Has your pet ever had any history of bleeding problems?

Is your pet currently experiencing any vomiting or diarrhea?

Is your pet currently coughing, sneezing, or having any eye or nose discharge? If yes to any of these, please explain at the bottom of this questionaire.

Please explain if you said Yes to any of the questions above.

Has your pet ever had any fleas or ticks?

Has your pet ever had any seizures/muscle tremors/loss of Coordination/shaking? If yes to any of these, please explain at the bottom of this questionaire.

Is your pet current on vaccinations?

Is your pet on any current medications?

Has your pet had any previous surgeries?

Does your pet have any handling sensitivity with strangers?

What additional services would you like done during your pet's stay with us?

For the check in process to be efficient and on time, please show up at your exact appointment time and do not arrive early or late. We are a high volume clinic and to manage a high volume of animals and clients checking in it is imperative for everyone to show up at their exact appointment time. Arriving early will not mean you will be seen early, you will have to wait until your appointment time to be seen and arriving late will mean that your appointment will have to be worked in and possibly be seen after all other appointments are checked in.

E-collar

Your pet is undergoing a soft tissue procedure today, we will send you home with an e-collar (the cone of shame) to ensure the best possible post-op recovery.

PRE-ANESTHETIC SAFETY MEASURES

Your pet will be under general anesthesia today. Because there is always the possibility that a physical exam alone will not identify all difficulties, we advise that a pre-anesthetic blood profile be completed prior to anesthesia for all patients. A pre-anesthetic blood profile is required for any pet between the ages of 5 - 8 years.

Chem - 10 Panel: Baseline panel that checks the Glucose (blood sugar), Creatinine (Kidney), BUN (Kidney), Total Protein, Albumin (Kidney/Liver/Hydration), Globulin (Kidney/Infection), ALT (Liver), ALP (Liver), Albumin/Globulin Ratio and BUN/Creatinine Ratio for additional analysis of internal organ function. In juvenile patients, this is performed to identify concerns such as anemia or birth defects of the liver or kidneys resulting in the poor function of these systems which may otherwise go undetected.

Please select an option:


General Anesthesia Consent

By signing below, I confirm that I am at least 18 years of age, and as the legal owner of this pet, give the Arizona Humane Society, its veterinarians, employees, volunteers, representatives, or agents, authorization to receive, vaccinate, prescribe for, treat, and operate upon your pet. I understand and acknowledge that the Arizona Humane Society uses modern techniques and trained staff in the care of my pet(s) and that reasonable precautions are used to prevent escape or injury to the animal or the handler(s). I understand that the limited physical examination the veterinarian will perform today is used solely to determine whether or not the patient appears healthy enough to proceed with anesthesia and/or receive vaccines. This exam is not meant to replace an annual complete physical exam, and will not include testing my pet for any diseases or diagnosing/treating my pet for any past, current, or future condition. The veterinarian cannot address medical issues unrelated to surgery and/or the administration of vaccines at this time. I further understand that the attending veterinarian may refuse to perform surgery and/or any vaccination if he/she believes it may endanger my pet's health in any way.
I understand and acknowledge that a surgical complication and/or an adverse reaction to medications or vaccine(s) may occur that would require medical intervention by the staff veterinarian. If additional treatment is needed beyond the initial intervention, I acknowledge that I am responsible for transporting my pet to a private veterinary clinic. I agree to pay all reasonable charges for procedures deemed necessary by the attending veterinarian to maintain a reasonable quality of life for my pet in this instance. I acknowledge that less immediate complications can also arise and that I will receive aftercare instructions. I understand that should my pet require post-operative care that is not a result of a surgical complication, I will be charged an office recheck fee as well as any additional costs associated with the treatment plan.
I will be informed of any changes in the proposed care and treatment of my pet, as well as any change in the condition of my pet. If I cannot be reached and/or an emergency situation arises, the hospital doctor(s) and staff are to use sound medical judgment in caring for my pet. I am to be informed of the discharge date for my pet, and will be expected to pay all charges in full upon the release of my pet.

• I understand that if my female pet is in-heat or pregnant and undergoing sterilization, the procedure may be more complicated and there can be a greater risk of post-surgical bleeding due to an increased blood supply to the uterus. If my pet is in-heat or pregnant, I accept that I will be charged a high-risk fee of $25.
• Should my pet be left in the hospital beyond the discharge date without prior arrangements, I understand I will be charged a $60 late fee or $100 overnight fee, whichever is applicable. I further understand that if I fail to contact AHS in this case, abandonment procedures will be initiated as outlined by Arizona State Law, and that I will be fully responsible for all accrued charges until my pet is removed from the hospital or considered abandoned by Arizona State Law.
• Should my pet be left in the hospital beyond the discharge date without prior arrangements, I understand I will be charged a $60 late fee or $100 overnight fee, whichever is applicable. I further understand that if I fail to contact AHS in this case, abandonment procedures will be initiated as outlined by Arizona State Law, and that I will be fully responsible for all accrued charges until my pet is removed from the hospital or considered abandoned by Arizona State Law.
• My pet will receive a small tattoo on his/her underside to show that he/she has been sterilized.
• The Arizona Humane Society understands that a visit to the veterinarian can be stressful for a pet. As a result, there is a chance that a complete exam may not be possible until my pet has been sedated. Although anesthesia in a healthy pet carries low risk, a small percentage of pets may have an underlying medical condition (such as a heart murmur) that may not be detectable without performing a thorough physical examination. I understand these risks and authorize the Arizona Humane Society to examine my pet under anesthesia if they are unable to complete a physical exam prior to sedation.
• To the best of my knowledge, my pet has not bitten any person within the last 10 days. I understand that if he/she has bitten someone within 10 days, I must inform the staff of the bite history.

By signing below, I confirm that I have fully read, understand, and agree to these conditions.


Does your pet have any of the following conditions?

If you selected any of the above conditions you MUST read the below terms and sign below if you would like to proceed with surgery. There is also a $25 high-risk associated fee.
Please note that the attending veterinarian may require a high-risk waiver for other conditions or may refuse to perform surgery if he/she believes it may endanger my pet's health in any way.

Heart Murmur
A heart murmur is caused by a disturbance in blood flow. The murmur is graded on how loud it is, and a high rating does not necessarily mean the underlying heart disease is more severe. There are many different causes of a heart murmur, which is why our best recommendation is to follow up with your regular veterinarian prior to surgery. We are willing to perform surgery on your pet with the understanding that anesthesia and surgery do pose a higher risk for complications including death. We may place an IV catheter in the leg of our high-risk patients so that we have immediate IV access in the event of a complication. There is a $25 high-risk fee if you elect to proceed.

Overweight/Obese
Overweight patients generally present more of a surgical challenge requiring more operating time and have a greater risk of bleeding during surgery than healthy patients. Additionally, your pet can have more trouble breathing in the time before, during, and after surgery due to the excess weight on his/her lungs as he/she is placed in various positions throughout the day. Our best recommendation is a weight loss of prior to surgery. We are willing to perform surgery on your pet with the understanding that anesthesia and surgery do pose a higher risk for complications including death. We may place an IV catheter in the leg of our high-risk patients so that we have immediate IV access in the event of a complication. There is a $25 high-risk fee if you elect to proceed.

Brachycephaly
A brachycephalic animal has a short nose and other anatomical abnormalities, such as small nostrils, which put them at greater risk for having trouble breathing. Our best recommendation is that your pet has surgery at your regular veterinarian, who can provide constant supervision throughout the pre- and post-operative period in the event your pet develops respiratory distress. We are willing to perform surgery on your pet with the understanding that anesthesia and surgery do pose a higher risk for complications including death. We may place an IV catheter in the leg of our high-risk patients so that we have immediate IV access in the event of a complication. There is a $25 high-risk fee if you elect to proceed.

By signing below, I confirm that I have read the conditions above and understand that my pet is considered high risk and I am okay with proceeding with surgery. I further understand that the attending veterinarian may refuse to perform surgery if he/she believes it may endanger my pet's health in any way. If your pet does NOT have any of the above conditions please write N/A in the box below.

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