Pre Surgical Questionnaire in Portland, TX | Portland Veterinary Hospital

Owner's Name(Required)

Patient Name(Required)

The questions below are extremely important to answer as correctly as possible. There is always a risk with anesthesia and surgery. Sometimes unforeseen complications do arise. We want your pet to have a good post- operative recovery without any secondary problems. To minimize the risk of complications, we start with a good history and physical exam.

Please check yes or no for each question:

Date of last vaccines(Required)

Where?(Required)

If yes, what is it?(Required)

lf you have any other information that can be beneficial, please make a note.

Signature(Required)

Date(Required)