De La Salle Araneta University VSUR101B Surgical Form

Patient’s Name:
Species: Owner’s Name:
Breed: Contact No.
Address:
Sex: Age:
Color Markings:

Surgical Procedure:_ Preoperative points:

Surgical Team: Operation proper points:
Surgeon: Post-operative points:
Asst. Surgeon:
Anesthetist: TOTAL:
Nurse:

ANIMAL PICTURE: (two different views)

Post-operative evaluation Date:

Prepared by:
Asst. Surgeon

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De La Salle Araneta University VSUR101B Surgical Form

SURGICAL MATERIALS NEEDED:

SURGICAL MATERIALS CHARACTERISTICS QUANATITY

SURGICAL INSTRUMENTS CHARACTERISTICS QUANTITY

Prepared by: Approved by:

Asst. Surgeon Surgeon

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 De La Salle Araneta University VSUR101B Surgical Form

SURGICAL PROCEDURE

Surgical Operation:
Animal position:

Organs Involve:

Location of Incision:

Organs/tissue to be incised:

Suture patterns used in closing the opened organs/tissues:

Suture materials used:

Procedure:

1.

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De La Salle Araneta University VSUR101B Surgical Form

Prepared by:

Surgeon

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 De La Salle Araneta University VSUR101B Surgical Form

ANESTHESIA RECORD
General anesthesia Local anesthesia Epidural /regional Anesthesia
Pre-anesthetic Drug:
Dosage:
Time of administration:
Route:
Anesthetic Drug:
Dosage:
Time of administration:
Route:

Surgery Starting Time: End:

Other Medicines Given (during the surgery):

Drug Name Dosage Route Time Given
1.
2.
3.
4.
5.

Pupillary dilatation size:

Time Checked Size
1.
2.
3.
4.
5.
6.
7.

Rectal Temperature
Time Checked Temperature
1.
2.
3.
4.
5.
6.
7.

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 De La Salle Araneta University VSUR101B Surgical Form

Heart Rate Evaluation

Time Checked bpm Remarks

Respiratory Rate Evaluation

Time Checked bpm Remarks

Other Medicines Given (after the surgery)

Drug Name Dosage Route Time Given Frequency

Prepared by:

Anesthetist

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 De La Salle Araneta University VSUR101B Surgical Form

POST-OPERATIVE CARE RECORD:

Drug Given Dosage Route Frequency
1.
2.
3.
4.
5.

Day 1

Day 2

Day 3

Day 4

Day 5d

Day 6

Day 7

Prepared by:

Nurse

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