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Anesthesia Form

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Cat Clinic of Destin Anesthesia 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. If this is an emergency, or if your pet needs urgent care, please call us at for a faster response.

Are you a new client?(Required)

Yes

No

Name(Required)

First Last

Email(Required)

Primary Phone(Required)

Secondary Phone

Address(Required)

Street Address Address Line 2 City State ZIP Code

Who else is authorized to make decisions about your pet's healthcare?

First Last

Phone

How did you find out about our hospital? If you were referred by someone, who should we thank?(Required)

Pet Information

Procedure to be performed:(Required)

If other, please specify(Required)

Pet's Name(Required)

Breed(Required)

Age/Date of Birth(Required)

Sex(Required)

Male

Neutered male

Female

Spayed female

Declawed?(Required)

Yes

No

Is your pet currently on flea prevention?(Required)

Yes

No

Is your pet up to date on vaccines?(Required)

Yes

No

Last vaccines (Vaccine Name and Clinic #)

Pre-existing health issues:

Please specify the procedure we're seeing your pet for:(Required)

Please check all that apply for your pet:

Is your pet currently taking medications?(Required)

Yes

No

Please list ALL current medications:(Required)

Insert a Microchip for Identification:(Required)

Yes

No

(Very few lost cats find their way home without permanent ID. We can implant this while sedated.)

Perform Pre-Anesthetic Blood work:(Required)

Yes

No

(Recommended to screen your pet for any illnesses that may complicate anesthesia)

Dentals Only: I authorize Dr. Flynn or Dr. Flaherty to do any x-rays, extractions or treatments deemed necessary while my cat is under anesthesia. I understand that I am responsible for any additional cost involved.(Required)

I have read and understand.

I hereby authorize Dr. Flynn or Dr. Flaherty at The Cat Clinic of Destin to administer anesthesia for the stated procedure or surgery. I understand that a very safe anesthesia will be administered and my cat will be monitored throughout the procedure until he or she recovers.(Required)

I have read and understand.

I understand that all anesthetics and surgical procedures have certain risk involved and that every precaution will be taken to minimize risks.(Required)

I have read and understand.

I understand that no guarantee exists as to the results of diagnosis and treatment of said cat.(Required)

I have read and understand.

If fleas or flea debris are found on my cat, I understand that he or she will be treated as deemed necessary by Dr. Flynn or Dr. Flaherty at my expense.(Required)

I have read and understand.

I understand that all cats brought into the clinic must be up to date on all required vaccinations. If I cannot provide proof that my cat has a current Rabies vaccination, he or she will be brought up to date while in the hospital today, according to state law.(Required)

I have read and understand.

I am the owner or agent of the above cat(s). I have the authority to execute this consent and am over the age of 18. I hereby authorize Dr. Flynn at The Cat Clinic of Destin to administer anesthesia for the stated procedure or surgery. I understand that a very safe anesthesia will be administered and my cat will be monitored throughout the procedure until he or she recovers. I understand that all anesthetics and surgical procedures have certain risk involved and that every precaution will be taken to minimize risks. I understand that no guarantee exists as to the results of diagnosis and treatment of said cat. If fleas or flea debris are found on my cat, I understand that he or she will be treated as deemed necessary by Dr. Flynn at my expense. I understand that all cats brought in to the clinic must be up to date on all required vaccinations. If I cannot provide proof that my cat has a current Rabies vaccination, he or she will be brought up to date while in the hospital today, according to state law.(Required)

Signature

Date(Required)

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Phone

This field is for validation purposes and should be left unchanged.

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Anesthesia Form

Cat Clinic of Destin Anesthesia Form

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