Patient Drop-off Form Patient Drop-off Owner’s Name * Owner’s Name First First Last Last Patient * Problem or Procedure * Annual Exam Rabies FVRCP FELV Fecal Labwork Wellness Labs For a problem, please answer the following: When did the problem start? Is the problem getting worse, better, or staying the same? Are other cats in the household showing the same signs? For all drop-offs, please answer the following: Change in appetite? No Change Increase Decrease Change in water intake? No Change Increase Decrease Change in urination? No Change Increase Decrease Change in defecation? No Change Increase Decrease Other change in litter box habits? (specify) Other change in behavior? (specify) What Brand of canned food does your cat eat? What Brand of dry food does your cat eat? Is your cat indoor, outdoor or both? What type of flea/heartworm prevention are you using? Other information that may be helpful: ESTIMATES CAN BE PROVIDED ON REQUEST! Some problems may require more than a physical exam to determine the cause. May we perform necessary tests? Yes Call First Once the cause is determined, may we begin treatment? Yes Call First May we sedate your cat if necessary? Yes Call First We advise setting a dollar limit after which we will call for further guidance Phone number you can be reached today Alternative Phone May we text you? Yes No Email * Signature * signature keyboard Clear Date * If your cat has fleas, ticks or other parasites, he or she will be treated at your expense Anesthetic Consent There may be minor surgery, but there is no such thing as minor anesthesia! We use Sevoflurane anesthetic gas exclusively when anesthetic gas is necessary. Sevoflurane is a stateof-the-art anesthetic gas that is used in 95% of human hospitals, including on neo-natal infants. Sevoflurane allows the doctor to better control the depth of anesthesia. It is gentler and less stressful for the cat when going to sleep and waking up than other anesthetic gasses generally used in veterinary hospitals. PRE-ANESTHETIC EXAM AND BLOOD TESTING: There is always a risk associated with anesthesia, regardless of the procedure to be performed. Most, but not all of these risk factors can be determined by a complete physical examination and pre-anesthetic blood testing. We further reduce these risks by using only top quality anesthetic agents, continuous human and electronic monitoring and the use of IV fluids when appropriate. ANESTHETIC COST: Each anesthetic procedure is designed specifically for your individual cat. The procedures and the agents used vary considerably depending on several variables, including the age and medical history of your cat and on the length and type of procedure being performed. The total cost may range from $49.00 to $250 or more. If PAIN MEDICATION or ANTIBIOTICS are necessary, do you prefer Pills or Liquid? Pills are usually a little less expensive, but may be more difficult to administer. Ask about “Pill Pockets”! Pills Liquid Resuscitation Orders in the Event of an Emergency: For every cat in our care, we need to know, in advance, what your wishes are in the unforeseen event of an emergency if he or she stops breathing and/or their heart stops beating. CPR has the best chance of being successful if started immediately. We will make every attempt to contact you right away should your cat require resuscitative efforts. Please review and select one option below. Cardiopulmonary Resuscitation (CPR): All resuscitative efforts including placing a breathing tube, providing chest compressions and IV medications are to be attempted to restore normal heart function and breathing as deemed necessary by the doctor until I can be reached. Should my cat require cardiopulmonary resuscitation (CPR), I request that the doctor(s) pursue such medical care indicated above. I understand that this is a cost in ADDITION to any estimate and agree to pay this fee. The cost of full CPR is typically an additional $300 - $500 or more. Patients who are successfully resuscitated are often critical and will require transfer to a 24-hour facility for at least 24 to 48 hours of intensive care and monitoring following resuscitation. Do Not Attempt Resuscitation (DNR): Aside from reversing any reversible sedatives or anesthetic drugs that have been administered, no cardiopulmonary resuscitation (CPR) efforts are to be attempted allowing natural death. Be assured that we do everything possible to prevent this from happening and electing DNR does not affect selected treatments. Please select one of the following: * Cardiopulmonary Resuscitation (CPR) Do Not attempt Resuscitation (DNR) AUTHORIZATION: By signing below, you are verifying that: I am the owner or agent for the owner of the above-described cat. I understand that during the performance of the ensuing procedures(s), unforeseen conditions may be revealed that necessitate an extension of the ensuing procedure(s) or different procedure(s) than those set forth above; therefore, I hereby authorize the performance of such procedure(s) as are necessary in the exercise of the veterinarian’s professional judgment. Signature * signature keyboard Clear Date * Captcha Submit If you are human, leave this field blank.
