Anesthetic Form

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Anesthetic Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Patient's Information

Pet's Name *

Surgery Day Contact Information

Name *

First

Last

Email *

Phone *

Additional Phone *

Secondary Contact *

First

Last

Secondary Contact Phone *

Today's procedure is: (example: spay, neuter etc.) *

Anesthetic Complications

Your pet will be receiving general anesthesia. It is to be understood that anesthesia ALWAYS carries some risk. Prior to administering anesthesia, a pre-surgical exam will be performed. Valley Veterinary Clinic uses very safe anesthetic protocols and close patient monitoring. Despite these measures there are times an animal may have an underlying problem which may not be physically evident and that can put a pet at higher risk for anesthesia. Pre-anesthetic testing can help minimize these risks and is required for all animals over the age of 5 years. This does not eliminate all anesthetic risk but provides us with a broader scope of your pet’s organ function and helps to rule out many internal problems that could lead to complications.
I understand that it is a policy of Valley Veterinary Clinic of Glasgow, PLLC (Valley Vet) that all surgical candidates be up-to-date on all required vaccinations. Documentation must be provided by drop off time or they will be given on the day of surgery.
I understand that my pet’s procedure requires general anesthesia and/or sedation. All precautions will be taken to ensure the safety of my pet. However, I have been informed of the possible risks associated with anesthesia, sedation, and that I am responsible for all associated charges and payment is due at time of service. I also understand that the doctor reserve the right to performed lifesaving efforts should complications arise.
I officially release Valley Veterinary Clinic of Glasgow, PLLC of any liability pertaining to this procedure (before, during, or after surgery).

Valley Veterinary Clinic requires pre-surgical bloodwork on pets over 5 years of age.
Pre-anesthetic blood work focuses on the liver and kidneys because these two organs are of prime importance in metabolizing the anesthetic drugs that we use. An added benefit of pre-anesthetic blood work is that it provides baseline values as a reference in case of future illness and may detect problems before they are clinically apparent.

Please select a pre-anesthetic service below if your pet is over 5 years of age: *

Pre-anesthetic screen: This is a six-test panel focusing on the major liver and kidney tests. Minimum required for all pets over the age of 5
General Health Profile: This is a twelve-test panel that provides more in-depth information about organ function and the body’s electrolyte balance.
General health profile + Complete Blood Count: This panel includes the twelve-test panel plus a complete blood count (CBC). A CBC measures the different cells that are present in the blood (White, Red, and Platelets).
General Health Profile + CBC + Thyroid: This panel includes the twelve-test panel, complete blood count, and a thyroid (T4).
My pet is under 5 years of age and I do not wish to have pre-anesthetic bloodwork performed on my pet.
Preventative Gastropexy: Stomach tack highly recommended for large dogs. Additional surgical cost associated.

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Anesthetic Form

Anesthetic Form

Patient's Information

Surgery Day Contact Information

Anesthetic Complications

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We proudly serve the pets of Glasgow, MT and the surrounding areas:

Wolf Point

Malta

Scobey

Opheim

Fort Peck

Plentywood