Owner's Name *

First

Last

Pet's Name *

Phone number where I can be reached at today: *

Alternate phone number where I can be reached at today:

Email *

In-Patient Questionnaire

Last time food was offered to patient:

Last time water was offered to patient: *

Has your pet had pre-surgical bloodwork done within the last 6 weeks? *

Yes
No

Blood work is required before general anesthesia.

We will be drawing the appropriate blood work today before surgery. Please be available by phone this morning so we can contact you should there be any significant issues we need to discuss with you. *

I have read and understand the above statement.

Is your pet showing any signs of illness today?

Yes
No

Please tell us what is going on today! We may need to postpone the surgical procedure, depending upon what is going on. We want to keep your pet as safe and healthy as possible!

Please give details as to what is occurring - vomiting, diarrhea, itching, ear/skin infection, etc.

Please list all medications your pet is taking: *

Please write N/A if your pet is not on any medications.

When was the last dose administered?

Is your pet on any heartworm or flea/tick preventative?

Has your pet had any previous reactions to anesthesia?

Yes
No

Please explain *

List any behavioral concerns (biting, timidness, needing special handling, etc.)

List any belongings left with your pet (i.e. carrier, leash, collar, etc.)

The hospital will not be responsible for any lost items.

Would you like a microchip implanted at the time of surgery for an additional $35 fee? *

Yes
No

I understand that I must register this chip on my own online to complete the activation process. *

I have read and understand the above statement.

What type of procedure is your pet having today? Check all that apply. *

Please Describe. *

For mass removals, would you like the mass submitted for biopsy? This is strongly recommended.

Yes
No
I would like to discuss it with the veterinary team.

The veterinary team will call you after the procedure to discuss if the mass should be submitted for biopsy.

During spay and neuter procedures, we check to make sure there are no retained baby teeth. If at the time of surgery, there are retained teeth, we recommend removing them while your pet is under anesthesia so it does not have to be done in the future. There will be an additional fee for removing the retained tooth/teeth. *

I have read and understand the above statement.

If during surgery, it is found that my pet may be pregnant, I allow the veterinary to proceed with the surgery as previously planned. I understand that this may add additional cost to the procedure. I DO NOT need a phone call during surgery.

True, I do not need to be contacted. Please continue with surgery.
False. I need a phone call!

I WANT A PHONE CALL during the procedure, if my pet is suspected/found to be pregnant. I understand that anesthesia can be fatal to the fetuses and may lead to spontaneous abortion. I also understand that anesthesia can cause serious birth defects. I accept that if the staff of Longmeadow Veterinary Clinic cannot reach me within 5 minutes of the initial phone call, they will continue with the surgery, and my pet will be spayed. I agree to still be responsible for any anesthesia and surgical charges. *

I have read and understand the above statement.

I accept the recommendations of the veterinarian and agree to any and all extractions that they feel are necessary. I DO NOT require a phone call before proceeding. I understand and accept that this may make my total bill higher than the signed estimate. *

I have read and understand the above statement.

I accept that the veterinarian at Longmeadow Veterinary Clinic are not board-certified dentists. Occasionally, there are circumstances that are undetectable before surgery that a board-certified dentist must address. I understand that it is in the best interest of my pet for a referral if the veterinary feels it necessary. *

I have read and understand the above statement.

Authorization Consent/Decline Directive for Cardiopulmonary Resuscitation (CPR)

I understand that the anesthetic, surgical or therapeutic procedures may involve the risk of complications, injury, or even death, from both known and unknown causes, and no warranty or guarantee has either been expressed or implied as to the result or cure. *

I have read and understand the above statement.

Please choose one of the following: *

I elect endotracheal intubation, positive pressure respiration, administration of emergency drugs, and/or external cardiac massage.
I elect NOT to have staff pursue any CPR procedures for my pet. Instead, I request that the attending veterinarian assist my pet in humane euthanasia if treatment will only prolong pain and suffering in the veterinarian’s medical opinion.

If I request such emergency procedures, I agree to be held responsible for veterinary services provided to my pet while staff members pursue treatment and try to reach me for further directions. The cost associated with this is typically between $300 and $500, over the initial surgical estimate given to me. Animals that have been successfully resuscitated are extremely critical and unstable. The likelihood of re-arrest is high and usually occurs within 4 hours of the initial arrest. If resuscitation is successful, there is only about a 20% chance that a pet will stay alive for the first 4 hours after resuscitation. The percentage of long term survival is even lower, and may be as low as 1%, depending upon what caused the arrest. Brain damage is common due to temporary lack of oxygen to the brain, which can result in blindness and/or impaired mental function, leaving a pet with physical and/or mental disabilities. This impairment may last for days, weeks, or years. Even in human medicine, statistics show that less than 10% of patients who are successfully resuscitated will leave the hospital without some degree of brain damage (contrary to what television shows lead us to believe). *

I have read and understand the above statement.

I accept that if the hospital staff is unable to reach me within 20 minutes after initial CPR procedures, and after exercising reasonable medical judgement or determining that there is no hope for success, the staff will cease further CPR procedures. *

I have read and understand the above statement.

I understand that despite the best efforts of the veterinary and support staff at the Longmeadow Veterinary Clinic, less than 5% of animals that require CPR fully recover to leave the hospital. *

I have read and understand the above statement.

By signing below, I confirm that I have read and understand the above policies. *

Clear Signature

Date *

Urgent Care Available by Appointment

Treatment Consent Form