Pre-Surgical Patient Information Form Owner Name* Patient Name* Today's Date* MM slash DD slash YYYY Owner’s Date of Birth (needed for prescribing certain medications by the DEA):* MM slash DD slash YYYY What time does your pet eat dinner?* : Hours Minutes AM PM AM/PM Approximately how much food does he/she eat?* Did you bring your pets medications here today?*Select OneYesNoIs your pet on any other medications besides eye medications?*Select OneYesNoIf so, please list the medication(s) and the dosage(s) below:Is your pet allergic to any medications?*Select OneYesNoIf so, please list the medication(s) below:Has your pet had any adverse reaction to a medication (oral, topical, injectable, etc)?*Select OneYesNoIf so, please list the medication(s) and the dosage(s) below:Has your pet ever had any adverse reaction to any procedures?*Select OneYesNoIf so, please list the procedure and what occurred below:Of the eye medications he/she is on, please indicate which medications you administered today and what time they were given.Is there anything else that you feel we should be aware of with regard to your pet’s health prior to surgery today?Has your pet ever had any seizures?*Select OneYesNoHas your pet ever had a past anesthetic event that you thought went poorly?*Select OneYesNoHas there been any history of neck, spine, or back disease in your pet? Any pain or discomfort in these areas?*Do you prefer eye ointments or drops?*Select OneEye OintmentsDropsNo PreferenceDo you prefer liquid medications or pills?*Select OneLiquid MedicationsPillsNo PreferenceIs your pet up to date with vaccinations?*Select OneYesNoDo you have any questions about the surgery today?*Select OneYesNoWould you like us to trim your pet's nails while they are under anesthesia? Applies to General Anesthesia Only*Select OneYesNoOnly applies to General Anesthesia. For our Diabetic patients, please fill out the following:What is his/her regular insulin schedule? (Please indicate both the time you administer the insulin and the dose given each time.)How much insulin was given today and at what time? How much food was also given?
