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Pre-Sedation/Anesthesia Questionnaire - Hernando Animal Clinic

Client First Name

Client Last Name

Pet's Name

Phone number to contact during procedure

Please be available to answer any call(s)/text(s) during the day of your pet's procedure to prevent delay on any potential care that may be indicated.

Type of Procedure

Date of procedure

Pet's Species

Is your pet on any medications/supplements

Is your pet on any medications/supplements
A
B

Please list all medications your pet is on

Pet's Gender

Does your pet have any medical conditions that we need to be aware of before sedation (heart murmur, diabetes, etc.)?

Does your pet have any medical conditions that we need to be aware of before sedation (heart murmur, diabetes, etc.)?
A
B

Please list any medical conditions

Time/Date of pet's last meal prior to procedure. Please do NOT offer any food after midnight prior to procedure. They can have water up until intake.

Is your pet allergic to any medications?

Is your pet allergic to any medications?
A
B

Please list all medications your pet is allergic to

Please indicate any changes in the following

Increase
Decrease
No Change
Weight
Urination
Water Consumption
Appetite
Energy Level

Has your pet had any of the following in the last 14 days?

Yes
No
Vomiting
Diarrhea
Coughing
Sneezing

Has there been any other changes in health or activity level at home?

Has there been any other changes in health or activity level at home?
A
B

Please explain

Resuscitation Directive

Your pet has been or will be admitted for hospitalization. The staff at Hernando Animal Clinic & Surgery Center will make every effort to prevent complications arising from your pets illness/injury or from procedures carried out in our hospitals. However, in some cases, there is risk that your pet may experience respiratory and/or cardiac arrest while hospitalized. We encourage an open discussion of all medical information between you and our veterinary staff prior to admission. Cardio-pulmonary resuscitation (CPR) is a difficult subject for many people, but one that is very important to review. All patients admitted to Hernando Animal Clinic & Surgery Center must have a resuscitation directive regardless of severity of illness.

We are requesting that you choose whether you want us to revive your pet in the unlikely event that your pet experiences respiratory and/or cardiac arrest. If your pet arrests, there is a short and critical window of opportunity to initiate CPR beyond which the success rate of cardio-pulmonary resuscitation decreases significantly. By selecting now, we will be able to initiate our efforts without delay. Once we have initiated CPR, we will contact you to make further decisions.

Please choose from the following options (below) and select the appropriate box. Should you change your mind at any point during your pet's hospitalization, please notify your pet's doctor so that we may follow your wishes. We will ask you to sign a new form with your revised choice.

Do you wish us to attempt resuscitation?

Please provide any additional information you would like to make known

Please attach any files that may be needed and/or requested

By signing below, I agree that I have answered all questions above as truthfully as possible. AUTHORIZATION: ALL FEES ARE DUE AND PAYABLE AT THE TIME SERVICES ARE RENDERED. We accept cash, Visa, Mastercard, Discover, and American Express. In addition, we offer third-party financing through CareCredit and ScratchPay. Please notify a receptionist if you need to apply for third-party financing prior to the start of your appointment. Current vaccinations by a licensed veterinarian are required for the admission of your pet to our hospital. Owner administered vaccinations are not acceptable. This includes admission for elective surgery, boarding, grooming, and well animal care. Proof of vaccinations is required prior to admission and is the responsibility of the client. I agree to allow the doctors and staff of Hernando Animal Clinic to treat my pet and I accept responsibility for all accumulated fees associated with the care that my pet(s) receive. I understand that I am responsible for payment in full prior to discharge according to Hernando Animal Clinic policy and will be held responsible for service or collection fees if balance is not paid in full. I have read and accept the above-mentioned terms and conditions by attaching my full name below as my digital signature.

Signature