Clinic Location CONSENT FOR ANESTHESIA OR SURGERY Date I, (Owner's name) (Phone#)( ) (Alt) of (Address), Street # City State Zip being a person over eighteen years of age, hereby authorize HSVMA/Rural Area Veterinary Services to perform on the following animal; surgical sterilization, vaccination and additional procedures deemed necessary, as determined by medical evaluation. I understand that the physical examination received by my animal is a basic one, and is not intended to detect all illnesses or injuries that may be present. Animal's name Dog / Cat / Other Male / Female Age Breed Color Surgical Procedure(s) requested: Spay / Neuter / Other. Declaration I am the legal owner/guardian of the above mentioned animal. I realize that there are inherent risks to any surgical or anesthetic procedure and these risks have been explained to me. I agree to indemnify HSVMA/Rural Area Veterinary Services, its volunteers and staff from any loss or liability. I understand that, as part of this clinic, veterinary students will be treating my animal, including physical examination, vaccinations and de-worming, anesthesia and surgery. All students will be under the direct supervision of a licensed veterinarian. Signed Date _ PATIENT HISTORY CLINIC USE ONLY How long has client cared for this animal? Hx taken by: < 1 month / 1-6 months / 6-12 months / 1-3 years / > 3 years Has this animal ever been to a veterinarian before? If yes, when Reason: Has the animal ever been treated at our clinics (HSVMA-RAVS) before? When: Has this animal been vaccinated before? When was last vaccine received? What vaccines were given at that time? Rabies DHPP FVRCP Other Has the animal ever had a reaction to a vaccination? In the past month, has this animal had any signs of illness or injury? (describe below) Illness: Sneezing Coughing Vomiting Diarrhea Eating more or less than usual Injury: Hit by Car Injured by another animal Other: Please describe: In the past month, has this animal been given any medications or home remedies? Please list: In the past month, has this animal been treated with anything for fleas or ticks? Product(s) used: Has this animal had any food in the last 12 hours? What time did they last eat? If the patient is a female: Has she ever had puppies/kittens? How many litters has she had? When was her last litter born? When was her last heat cycle? Might she be pregnant (per client)? Where is this animal housed? # Mostly indoors / Mostly outdoors / Both indoors and out Including those brought today, how many animals are in the household? Dogs: Cats: Before today, how many of the animals in the household were spayed / neutered? Dogs: Cats: Has this animal bitten anyone in the past 3 years? (survey question only) Are there any other questions the client has about this animal s health or behavior? _ HISTORY AVAILABLE Page 1 [Discharge (DVM/RVT): ]
# Age: PHYSICAL EXAM / TREATMENT RECORD Species: Canine / Feline Sex: Male / Female (0-4 mos = pediatric) / (4-6 mos) / (6-12 mos) / (1-3 yrs) / (4-6 yrs) / (6-10 yrs) / (>10 yrs) Previous medical history / Recent illness/injury: Behavior: Gentle / Social Fearful / Possible Caution Aggressive / Feral _ PHYSICAL EXAM Examined by: time: Wt lb Temp o F Pulse bpm Resp Rate bpm MM/CRT / BCS (1-9): Hydration (adequate/ marginal/ inadeqaute): Mentation: GA INTEG EENT CV RESP NERV M/S ABD/GI GU PLN Addtl Comments: External Parasites: None Fleas or flea dirt Ear mites Ticks: 1-10 / > 10 Mange -- Sarcoptes / Demodex -- Dx based on: Clinical signs / Microscopic ID RAVS Animal Condition Score: Excellent Good Fair Poor Critical Reason for RAC Score assigned: Examined by veterinarian / staff technician? DVM/RVT: time: DVM/RVT Notes: TREATMENT RECORD (mark only after treatment has been completed) Vaccinations: Given by: time: Rabies 1 yr / 3 yr certificate & tag (# ) DHPP FVRCP Antiparasitic: Pyrantel: ml PO Ivermectin: ml PO / SQ Praziquantel: mg PO Flea/Tick Tx Administered: Frontline / Revolution / Advantage: ml Other: Idexx Snap Test: 4Dx Snap: Heartworm ( + ) / ( - ) Erlichia ( + ) / ( - ) Lyme ( + ) / ( - ) Anaplasma ( + ) / ( - ) Parvo Snap: ( + ) / ( - ) Felv/FIV Snap: ( + ) / ( - ) Heartworm Snap: ( + ) / ( - ) PCV/TP (result: / ) istat (attach results) Skin scraping (result: ) Other Labs: Other Tx MEDICATIONS DISPENSED (include anti-parasitics) Drug Dispensed Strength Qty Dosing Instructions Dx / Reason By Page 2 (02/09)
ANESTHESIA / PROCEDURE RECORD Alerts: Age: Animal Name: Last Name: Ax Cleared: IV Catheter: size g / location: Weight: Pt # lb = kg Premed: / Dose: / ml Route: Time: Induction: / Dose: / ml Route: Time: Other: Dose: ml Route: Time: Penicillin: ml Route: Time: Ketoprofen: ml Route: Time: Regional: Maintenance Anesthetic: ET tube size: System: NRB / Circle Procedure: Recumbency: Student Surgeon: DVM: Anesthetist: Time * O 2 (L/min) Iso (%) SpO 2 BP [sys/dias/ (MAP)] HR RR Temp MM/CRT Fluids Notes Pre-Induction Assessment: Induction Plan: ml/hr = drip/bolus rate: Tot Vol Admin * Α Begin Anesthesia End Anesthesia S Begin Surgery End Surgery R Arrival in Recovery Total Ax Time: min Total fluid admin: ml Extubation time: Tx Needed in Recovery: (Completed Tx must be noted on Tx Record) _ Medications Administered in Recovery: Drug: Dose: Route: Time: Drug: Dose: Route: Time: Drug: Dose: Route: Time: IVC removed: Post-Sx snack (<4mos): Returned to kennel: Page 3 (02/09)
# PROCEDURE REPORTS ANESTHESIA REPORT - (To be completed by anesthetist) Total Ax Time: min SURGERY REPORT - (To be completed by primary surgeon) Student Surgeon: DVM: Total Sx Time: min (explanation required for any Sx > 45 mins) ADDITIONAL PATIENT TES Page 4 (02/09)
ANIMAL CARE RECORD HSVMA / Rural Area Veterinary Services Client Name: Animal # Date: Animal's Name: Clinic Location: Exam Notes: Vaccinations/Treatment: Rabies: 1 year / 3 year (Tag # ) due again Canine DHPP (Distemper/Parvo) Feline FVRCP (Respiratory viruses) Flea / Tick Treatment: Frontline / Revolution / Other: due again due again due again Deworming-general (Pyrantel) due again Deworming + mange treatment (Ivermectin) due again Other Tests/Treatments: Medication(s) Dispensed: Medication Strength Qty Instructions Surgery performed: Spay (ventral / flank) Neuter Other Procedure: We strongly recommend the following for your animal's long-term health: Booster vaccinations every year or as recommended by your veterinarian. Yearly test for heartworm (blood test) and monthly heartworm preventative for dogs. Booster vaccinations every year or as recommended by your veterinarian. Yearly test for heartworm (blood test) and monthly heartworm preventative for dogs. Other:
POST-SURGERY CARE INSTRUCTIONS Your animal has just undergone general anesthesia and surgery. For the safety and well-being of you and your companion, the following instructions must be carefully followed: 1. DIET: When any anesthesia is used, stomach upset can occur. To avoid this, restrict the amount of food and water your animal has access to upon returning home. Animals can be fed 1/2 of their normal meal this evening. All animals can resume their normal diet beginning tomorrow morning. 2. EXERCISE: Keep your animal INDOORS tonight. Restrict his/her activity for the next 7 days. No running, jumping, swimming or bathing for the next week. If your pet is a FEMALE, keep her away from male dogs for the next 2 weeks. Rest is important for post-operative healing. 3. INCISION: You should check the incision every day until it is healed. A small amount of blood seepage is normal immediately after surgery. Should you notice any continued bleeding, draining or swelling contact us at the number provided immediately. If the incision should become dirty, gently clean the area with a cotton ball and hydrogen peroxide. Do not allow your animal to lick or chew at the incision. 4. SUTURES: If your pet's surgery required the use of sutures, the sutures are dissolvable and will not need to be removed. 5. DO T give aspirin, Tylenol or other human medications for pain relief. These medications can be harmful or fatal to animals. 6. IMPORTANT: Should your animal show ANY of the following signs, please call the HSVMA/RAVS veterinarian or your local veterinary clinic immediately: Unwillingness to eat or drink for more than 24 hours Straining to urinate or defecate Whining or resistance to being handled Blood or any material coming from the incision Unwillingness to move or stand Swelling of incision site Abnormal breathing IF YOU HAVE ANY CONCERNS ABOUT YOUR ANIMAL'S CONDITION AFTER SURGERY PLEASE CONTACT HSVMA-RAVS STAFF AT (831) 442-8359. SEE THE BACK OF THIS FORM FOR A RECORD OF THE SERVICES YOUR ANIMAL HAS RECEIVED TODAY. (02/09)