Surgery CHECK-IN QUESTIONNAIRE Surgery CHECK-IN QUESTIONNAIRE Name First Last PhoneHave you noticed vomiting/diarrhea/coughing/sneezing or wheezing in the last 7 days?* Yes No Is your pet on any medication? If so, what type, how often?Does your pet have a history of allergic reaction or difficulty following anesthesia?* Yes No Unsure/Never been under anesthesia When was your pet's last heat (female pets only)? Every pet needs to be microchipped in case of loss, being startled or stolen. Doing that during surgery is a great time to ensure pain free experience. Please choose below if you would like your pet to be microchipped with a T-CHIP (temperature reading chip)* Yes No For more information about the temperature microchip, please copy and paste this link into a new browser window: https://partner.24petwatch.com/Shelter_Vet/t-chip.aspxDoes your pet have hernias/retained teeth/retained testicles/dewclaws?* Yes No Unsure Are there any other concerns or questions you have for the veterinarian?Consent* I agree to CPR being performed in case of arrest I elect a “Do Not Resuscitate” status in case of arrest Please note, we must ask this question for safety reasons. We absolutely do not anticipate any anesthetic problems, but we need to know in the unlikelihood we are faced with this situation. Basic CPR is always performed as part of our anesthetic protocols, but if you would like us to go above and beyond, you must acknowledge that certain fees will apply (approximately $600). If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion. If you cannot be reached by phone within 20 minutes of CPR being initiated and your pet is unable to support cardiac or respiratory function on their own, I authorize the doctor on duty to make the best decision (considering quality of life) to discontinue CPR which may result in my pet's death. Agreement* I agreeBy submitting this form, you agree you have read and understood all parts, are the authorized person to make this decision (lawful owner), and you agree to pay Trenton Pet Hospital for the services provided.