Surgical Consent Form

Client Name

First NameLast Name

Patient Name

Requested Surgical Procedure

Date

It is difficult to predict all circumstances of a procedure and thus variations in cost may occur. If during hospitalization or surgery, a change in treatment or new problem is found, an attempt will be made to contact the owner to inform them. If contact cannot be made a decision may have to be made regarding the urgency of the procedure. In this case, if it is deemed life threatening, the procedure may be performed without notification.

Emergency Phone Number

May we text you pictures and updates? If so please list a text number below.

Cell Phone Number

Is your pet currently taking any medications?

YesNo

If yes, please list any prescription, over the counter medications, or supplements AND date and time of last dose.

Does your pet have any allergies that you know of?

YesNo

If yes, please list allergies

RISKS:

The anesthetic risk of serious complications from routine procedures on healthy animals is less than one in 5000 in our practice. The risk is higher in animals with health problems. The required physical examination will discover 95% of these problems. Pre-operative procedures such as x-rays, blood tests and electrocardiograms may help detect underlying problems that are not apparent from physical exam and history. Health problems that increase the risk are more likely in animals over eight years old. While helpful, all of these tests together would increase the cost by $170 to $250. Therefore they are usually not done unless there are known risk factors, suspicious signs or if the owner requests them. If you wish this or other preoperative blood tests we can provide them at the East Suburban Animal Hospital even on the same day as surgery. A packed cell volume, total protein, white blood cell count, BUN, ALT and Glucose are highly recommended in animals over 8 years old. Please advise us before surgery.

I decline blood testsI authorize blood tests ($90.00-$95.00)

For Tumor Removals Only - Histopathology is the microscopic examination of the surgically removed tissue used to study the manifestation of disease. Histopathology lets us know what type of tumor is present on your pet.

I decline HistopatholgyI approve Histopatholgy ($125.25)

PAIN MANAGEMENT

Animals have pain with surgery and we feel an obligation to provide pain relief. This will be provided the morning of the surgery before the surgery begins, during the surgery and for 3 - 7 days afterward depending on the type of surgery. A supply of pain medicine will be dispensed or prescribed for you to give at home. The doctor will decide on a case-by-case basis which medication is best for your pet. The quote given with the estimate is the cost of our usual protocol but may vary as indicated. I understand that no guarantee for success can be given and that some risks are involved in all procedures. The risks have been explained to my satisfaction and the East Suburban Animal Hospital has my permission to perform the above procedure.

REQUESTED VETERINARIAN:

A specific veterinarian will perform the procedure ONLY IF REQUESTED AND INITIALED HERE. I understand that in an emergency situation, any veterinarian at the East Suburban Animal Hospital may need to take action and give needed care and there may be additional charges.

I understand East Suburban Animal Hospital is NOT a 24 hour facility.

Specific Veterinarian or write N/A Initial

I understand East Suburban Animal Hospital is NOT a 24 hour facility.

Surgery patients are discharged in the back of our building. Please park in the rear parking lot, go up ramp, and ring the doorbell. One of our technicians will go over all of your pets post-surgery care. We make every effort to call you after your pet has waken from surgery, however if you do not hear from us, please call after 4:30 pm to check when they may go home.

If your pet is going home the following day, discharges before 1:00 pm are done at our cashier location in the front of the building and after 1:00 pm at the back. By electronically signing below I authorize East Suburban Animal Hospital to perform the above listed services.