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  - Surgical Questionnaire Form
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Home
About Us
- Testimonials
Our Team
Services
Resources
- Our Policies
- Online Forms
  - New Client Form
  - Surgical Questionnaire Form
Online Pharmacy
Contact
Request Appointment

Surgical Questionnaire Form

Provide essential health information for your pet by filling out our surgical questionnaire before their procedure.

Surgical Questionnaire Form

Please fill out the surgical questionnaire form carefully and accurately to ensure the best possible care for your pet during surgery.

Surgical Questionnaire Form

Owner Information

Name *

First

Last

Email *

Phone *

Pet Information

Pet’s Name *

Species *

Breed *

Sex *

Male
Neutered Male
Female
Spayed

Age *

Procedure Details

Scheduled Surgery *

Date of Surgery *

Has your pet had surgery before? *

Yes
No

If yes, were there any complications? *

Medical History

Does your pet have any known medical conditions? *

Yes
No

If yes, please specify: *

Is your pet currently on any medications or supplements? *

Yes
No

If yes, please list them: *

Has your pet shown any signs of illness recently (e.g., vomiting, diarrhea, coughing)? *

Yes
No

If yes, please describe: *

bleeding medications medications

Does your pet have any allergies (including medications)? *

Yes
No

If yes, please list them: *

Has your pet experienced any unusual changes in appetite or thirst recently? *

Yes
No

If yes, please describe: *

Has your pet received vaccinations and preventative care up to date? *

Yes
No

Feeding and Preparation

When was the last time your pet ate or drank?

What did your pet eat or drink?

Surgical Authorization and Concerns

Has your pet ever undergone anesthesia before? *

Yes
No

If yes, were there any complications? *

Does your pet have any bleeding tendencies or history of clotting disorders?

Yes
No

If yes, please explain: *

Has your pet been diagnosed with any heart, lung, or kidney conditions?

Yes
No

If yes, provide details: *

Are there any concerns or questions about the upcoming procedure?

Do you authorize the use of pain management medications for your pet during and after surgery?

Yes
No

Emergency Contact

Name *

Phone

Acknowledgment *

I confirm that the information I have provided is accurate and complete to the best of my knowledge. I understand that surgical procedures carry inherent risks, including potential complications, and I have had the opportunity to discuss these risks with the veterinary team. I also acknowledge that every effort will be made to ensure my pet’s safety and well-being throughout the procedure. By signing below, I give my consent for the veterinary team to perform the surgery as discussed and to administer any necessary care during and after the procedure.

Signature *

Clear Signature

Today's Date *

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We proudly serve the pets of Midland, TX, Odessa, TX, Big Spring, TX, Andrews, TX, Greenwood, TX, Lamesa, TX, and the surrounding areas. We hope to meet you and your furry friend soon! Click the button to request an appointment.

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Location

1301 N Big Spring St.
Midland, TX 79701

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Contact Information

Phone: (432) 682-3524
Email Us

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Hours

Mon – Fri: 8 AM – 5 PM
Sat – Sun: Closed

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Last

Email *

Phone

How can we help you? *

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