Small Animal Pre-Surgical Screen Sheet

Date *

Name *

Pets Name *

Age *

Species *

Breed *

This pre-surgery check in is designed to help us screen for any concerns before your pet is brought into us for surgery. Please print out this sheet, fill it out, and bring it in with you to your appointment. Alternatively, you can scan this sheet and email it back to us at info@peacerivervet.com.

History Questions (Answer for the past 14 days):

What does your pet eat (Wet, kibble, other) + Brand: *

Is your pet indoors or outdoors? *

Indoors
Outdoors
Both

How are energy levels? *

Normal
Increased
Decreased

How have drinking habits been? *

Normal
Increased
Decreased

How has urination been? *

Normal
Increased
Decreased

How has your pets stool been? *

Normal
Soft
Hard
Diarrhea

Any vomiting? *

Yes
No
Unknown

Any coughing? *

Yes
No
Unknown

Any sneezing or nasal discharge? *

Yes
No
Unknown

Any squinting or ocular (eye) discharge? *

Yes
No
Unknown

Concern over weight gain or loss? *

Yes
No
Unknown

Any vaginal or penile discharge? *

Yes
No
Unknown

Any new masses noted? *

Yes
No
Unknown

Any bloating or abdominal distension? *

Yes
No
Unknown

Any new skin lesions or pruritus (itchiness) noted? *

Yes
No
Unknown

If you answered yes or abnormal to any of the above questions, please describe below:

If your pet is a female, when (if ever) was her last heat cycle?

If your pet is female, has she ever been pregnant or given birth?

Yes
No

What medications or supplements is your pet currently taking (Medication name, dose, and last taken medication):

Please check off if any of these have been a previous health concern:

Known allergens *

If other, please specify *

If you checked off any of the above, please elaborate below:

Additional Services at time of surgery

Do you need a cone OR after surgery-wear to go home with? This is highly recommended to prevent licking/chewing at the incision after surgery, preventing infection and dehiscence (sutures coming apart).

CONE (Cost $10-$42 depending on size)
After-Surgery Wear (Cost $21-$39 depending on size)

Is your pet up to date on core vaccines? *

Yes
No
Unknown

If not, would you like these to be updated at time of surgery? *

Yes
No

CORE Vaccine ($76.20) *

Yes
No

Rabies Vaccine ($33.20 (dogs)-$42.60 (cats)) *

Yes
No

Would you like the option of Bordetella (Kennel cough vaccine) to be administered today if not up to date? This is for dogs only. (Cost: $33.20) *

Yes
No

When was the last time your pet was dewormed? *

Would you like us to send your pet home with a deworming medication today? (Cost is depending on the size and species) *

Yes
No

Would you like your pet to have their nails trimmed at time of surgery? (Complimentary) *

Yes
No

Would you like your pet to be microchipped at time of surgery? (Cost $87.80) *

Yes
No

Pre-anesthetic bloodwork is an option available to our pets that helps us to screen for concerns that might impact the anesthetic and surgery. This includes looking at blood glucose, proteins and the liver and kidney values. If there are any concerns, we may consider changing the drugs used during the general anesthetic, or with significant concerns may delay the surgery for another date while we pursue treatment or other diagnostics. Would you like pre-anesthetic bloodwork? (Cost $68.10) *

Yes
No

During this surgical procedure we will be placing your pet under general anesthesia. This state of unconsciousness is an unnatural state, and so carries risk. The risks for surgery include hypotension (low blood pressure), hypothermia or hyperthermia (high or low body temperature), hemorrhage (bleeding), infection, and allergic response to the anesthetic drugs used. More serious risks include cardiac events, stroke, and death. Anesthetic deaths are rare, and to limit the above risks, each patient undergoes a pre-anesthetic physical exam to ensure our patients are in good health, as well as a review of their medical history. Our patients are closely monitoring during surgery, measuring their vitals, blood pressure and other important parameters throughout the procedure. They also have intravenous fluids throughout the procedure for additional support.

Although there are risks for this elective procedure, the benefits include reduction of overpopulation, as well as:

Females:

Significant reduction in the risk of breast tumors.

Elimination of risks of infections of the uterus (pyometra), which can be life-threatening.

Eliminates risks of uterine & ovarian cancer.

Eliminates behavior associated with heat cycles.

Males:

Decreases risks of prostate enlargement and cancer.

Decreases behavior issues, such as roaming, spraying/marking, and fighting.

Eliminates risks of testicular cancer.

Do you have any questions you would like answered during surgery drop off?

Please remember that your pet needs to be fasted before surgery. No food after 8PM the night before and NO breakfast the morning of surgery but water is allowed. If your pet has eaten before coming in, we may reschedule their surgery. Thank you so much for trusting us with the care of your pet! If you have any further questions or concerns, please do not hesitate to reach out.

Best Wishes,

From your team at Peace River Veterinary Service

History Questions (Answer for the past 14 days):

Additional Services at time of surgery

Ready to make an appointment?