Administrative Hours: 8:30 am - 6:30 pm, Wednesday - Saturday | 6225 42nd Ave. N., Minneapolis, MN 55422
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Updated History: Follow-Up Clinic
PLEASE FILL OUT THE FOLLOWING BEFORE YOUR PETS VISIT AT THE FOLLOW-UP CLINIC
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What is your (the client's) name?
(Required)
First
Last
Phone
(Required)
Email
(Required)
Are you coming in for a:
(Required)
Chronic Disease/Follow Up Visit
Surgical Consultation Mass Removal
Surgical Consultation Orthopedic (Previously Diagnosed Concern)
Qualify of Life/End of Life Consultation
Let's Get Some Basic Information on Your Pet!
What is your pet's name?
(Required)
CPR Status
(Required)
CPR status is required for all visits regardless of concern: In the event that your pet should experience cardiac or respiratory arrest while in clinic today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of their status? Estimated cost for CPR is about $300 - $400
Yes, I agree to CPR being performed in case of arrest
No, I elect a "Do NOT Resuscitate" status in case of arrest
Prior Diagnoses and Current Medications
Which medical conditions has your pet been diagnosed with?
(Required)
press + to add more diagnoses
Condition Name |
Date Diagnosed |
Currently Being Treated (Yes/No)?:
Is this what we're seeing your pet for today (Yes/No)?
Add
Remove
Is your pet taking any medications, or have they recently discontinued any medications?
(Required)
Yes
No
Please list all medications, supplements, and preventatives your pet is currently taking
press + to add more medications
Medication Name?
Strength?
When/How much is given?
How long has your pet been on this medication (e.g. 3 years)?
Are you requesting refills or a renewed prescription for this medication?
What is this medication for?
Add
Remove
How has your pet been doing on their medication(s)? Do you have any concerns?
(Required)
Please list any medications that were discontinued and let us know why.
press + to add more medications
Medication Name
What was it prescribed for?
Why was this medication discontinued?
Add
Remove
Patient Update and Visit Goals
Please list your pet's food
press + to add more food
Name and Flavor |
Amount Per Feeding |
How Many Times Per Day:
Add
Remove
Have you changed their food recently?
No, not recently
Yes, within the past 24-48 hours
Yes, within the past week
Yes, transitioned slowly using the old and new food
Please describe your pets eating habits
(Required)
Eating Normally
Eating More
Eating Less
How are your pet's energy levels?
(Required)
Normal/good
Energy levels seem somewhat lower
Energy levels are significantly lower
My pet has no energy and is severely lethargic
Please describe your pets drinking habits
(Required)
Drinking Normally
Drinking More
Drinking Less
When was the last time your pet ate?
(Required)
Does your pet show any interest in food (even if it's just high value foods like treats, baby food, meats, etc.)?
Yes, they still seem interested in food even though they're eating less.
Yes, they seem interested, but in high value foods only.
No, they seem completely disinterested in all foods.
I haven't tried feeding my pet other kinds of foods.
I'm unsure
Does your pet still seem hungry after they've eaten?
(Required)
When was the last time your pet drank?
(Required)
How often is your pet drinking?
(Required)
Where is the mass located?
How long has the mass been there (since you first noticed)?
Since you've noticed the mass has it:
Remained the same size
Grown slightly
Grown significantly
Is your pet experiencing any of the following:
Difficulty breathing
Difficulty with movement
Itching/pain at the mass site
Bleeding at the mass site
How has your pet been doing since they were last seen?
(Required)
Do you have any new concerns or specific questions you'd like addressed at this visit?
(Required)
Which orthopedic surgery does your pet need?
Where was this diagnosed?
What kind of imaging did they do to diagnose the issue?
Please make sure to send any imaging to us or bring it with for your visit.
Do you feel your pet's pain is well controlled?
Yes
No
I'm unsure
Is there anything else you would like the veterinarian to know about your pet and their health??
Are there any specific questions you'd like the veterinarian to address during your quality of life consultation?
Consent for Treatment and Acknowledgments
Payment and Estimates
(Required)
Payment:
Payment is due in full at the time of service. Payment plans are not available through Access Veterinary Care, but are available through approved third-party providers. A list of 3rd party providers can be found on our FAQ page or at myaccessvetcare.com/AFR. The paying party is required to pre-qualify for those services before services are provided.
Estimates:
Access Veterinary Care strives to make our prices as clear as possible. General pricing is available online and pricing is discussed with clients prior to treatment. Estimates are made as comprehensively as possible, with an ideal course of treatment in mind, but may not accurately reflect the final total. Additional treatments may be required beyond those listed in the estimate, and the client is responsible for those additional services. If you indicated a specific budget for your visit, a comprehensive estimate will still be provided with the ideal course of treatment. The medical team will then use their discretion to determine which procedures, diagnostics, and/or treatments would most benefit your pet, taking your budget into consideration.
Treatment Outcomes:
Any treatments or procedures come with their own risks and no guarantees for successful treatment can be made. All financial obligations remain regardless of the outcome.
I understand and agree to the estimate and payment terms
Visit Terms, Conditions, and Risks
(Required)
Pet Management:
All pets must remain on leash or in a carrier while on property, which includes the parking lot and all common areas. To prevent the transmission of communicable diseases and protect pets from harm, clients are required to manage their pets in a way that reduces contact and interaction with other pets on Access Veterinary Care property.
Felines: Clients may be refused service or asked to register again another day if their cats are not crated upon arrival. If you do not have a crate, please inform the administrative staff and arrangements will be made. This is required for the safety of the pet and staff.
Authorized Party:
By agreeing to these conditions, you acknowledge that you are over 18 years of age, and have the authority to grant consent for this patient to receive medical care by Access Veterinary Care staff. You further verify that all given information is true to the best of your knowledge.
Sedation, Anesthesia, and Surgery:
Should your pet need sedation or anesthesia at their appointment, your medical team will discuss this with you prior to treatment:
Just like with humans, there are always risks and complications associated with sedation, anesthesia, and/or any operation/procedure. These risks are rare but can never be completely eliminated. Risks for anesthesia vary, but may include failure of the procedure requiring continued care, allergic reaction, respiratory distress, and other complications up to, and including, death of the patient.
The outcome of any treatment and procedure cannot be guaranteed. Surgical complications are rare, but present with any procedure. While some procedures carry a higher level of risk than others, they generally include post-surgical infection, dehiscence (incision opening after procedure), failure of the procedure, hemorrhage (bleeding), and other complications up to and including death of the patient. Other risks are more specific to particular procedures (such as jaw fractures for patients with severe dental disease).
During the course of any operation, treatment, or procedure in clinic, unforeseen conditions may arise that may necessitate the performance of additional procedures. Access Veterinary Care staff will always make a good faith effort to reach the client before additional services are rendered; however, certain treatments may be immediately required without advance notice and the client will be responsible for all associated charges. The Veterinarian will make these decisions based on the best interest of the patient and any previously noted client wishes.
We encourage you to discuss any concerns you have about procedure, treatment, and anesthesia risks with the Access Veterinary Care medical team before treatment is initiated.
I understand and agree to the visit terms and conditions. I understand the outlined risks IF my pet should need anesthesia or sedation during this visit. I understand that I am encouraged to ask any questions I might have before treatments or procedures are performed.
Electronic Signature
(Required)
First Name
Last Name
Date
Email
This field is for validation purposes and should be left unchanged.
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