Anesthesia and Surgery Consent

Patient / Client*

Pet's NameOwner First Name Owner Last Name

Owner Email*

example@example.com

Pet Information*

AgeSexBreed

I do hereby certify that I am the owner/guardian/agent of the pet described above and have full authority to execute this consent. I certify that my pet has not eaten in the last 8-12 hours as recommended. I give my full authorization and consent to have the veterinarians of Parkland Veterinary Hospital to perform the surgical procedures listed below.

Select Procedure(s)*

Any Comments or Concerns?

Pre-Surgical Blood Work: Your pet’s risk of complications during and after anesthesia and surgery is tremendously greater if there is preexisting organ disease, malfunction, or failure. We require blood work before anesthesia and surgery to help rule out these problems or identify them and devise an alternative treatment plan to meet your pet’s unique needs. These blood panels provide immensely valuable information.

Pets under 5 years of age: We perform a blood chemistry profile that assesses liver values, kidney values, blood glucose, and blood proteins. Pets over 5 years of age: We perform a COMPREHENSIVE blood chemistry profile that assesses liver values, kidney values, blood glucose, blood proteins, calcium, phosphorous, cholesterol, and more.

Post-Surgical Pain Management: The anesthetic protocol chosen by our doctor provides relief from pain during and up to 4-6 hours after surgery. For this reason, your pet should be comfortable, although possibly a little drowsy, upon discharge. One set of pain medication(s) will be sent home to be used after all surgical procedures for continued comfort and pain relief. Any additional or prolonged medication will be at owner's expense.

Healing and Recovery: We use Laser Therapy at the end of each surgical or dental procedure to help reduce inflammation, pain, and swelling. This treatment is proven to enhance and speed-up the healing process. As a result, we require one treatment at a minimum, but recommend the following:

SURGERY HEALING THERAPY (for larger incisions or multiple dental extractions), which is a set of FIVE laser sessions to speed up the healing process and shorten the healing time for $195. Do you want Laser Therapy for better post-surgical healing of muscle, bone, nerve, tendon, and ligament?*

YES, I DO want the Surgery Healing Therapy for my pet ($195)NO, I DO NOT want post-surgery therapy.

THE RECOVERY PACK, which is a set of three laser sessions proven to assist with healing and recovery for $169. Do you want Laser Therapy for better post-surgical healing of muscle, bone, nerve, tendon, and ligament?*

Yes, I Do Want The Recovery Pack for my pet ($169)NO, I DO NOT want post-surgery therapy.

THE DENTAL CARE PACK, which is a set of three laser sessions that can help reduce gingivitis, inflammation and gum pain?*

Yes, I Do Want The Dental Pack for my pet ($149)NO, I DO NOT want gum inflammation treatment therapy.

CHROMOSPHORE+BLUE LIGHT THERAPY, speeds up closure of skin incision site and repairs damaged skin due to either surgery or wound care. Do you want Chromosphore Light Therapy for post-surgical skin and dermis repair?*

Yes, I Do Want CHROMOSPHORE+BLUE LIGHT THERAPY for my pet ($107)NO, I DO NOT want post-procedure skin repair therapy.

Microchip Implantation: 1 in 3 pets go missing during their lifetime, and without proper identification, 90% never return home. A microchip is a form of permanent identification implanted under your pet’s skin. The microchip is about the size of a grain of rice, is placed in a matter of seconds, and helps keep you connected to the pet you love, forever. Once registered, you can update your pet’s online profile to include his/her picture and any pertinent medical information: Our microchip ($98) includes:

a) FREE LIFETIME REGISTRATION and

b) All-in-one Temperature Sensor which eliminates the need for very intrusive and uncomfortable Rectal temperature checks at veterinary appointments.

Do you want to microchip your pet?*

ALREADY CHIPPEDYESNO

I authorize the doctors and supporting staff of Parkland Veterinary Hospital to perform services, diagnostic procedures, and treatments deemed as necessary to improve my pet’s quality of life and provide quality veterinary care. I authorize the use of all anesthetic agents, sedatives, tranquilizers, and other medications and supportive care before, during, and after my pet’s procedure deemed as necessary by my pet’s attending veterinarian. I understand that hospital support personnel will be employed as deemed necessary by the attending veterinarian. I have been advised of the risks and possible complications of my pet’s procedure and that results and/or expected outcome cannot be guaranteed. If for any reason an emergency situation arises with my pet, the doctors and supporting staff of Parkland Veterinary Hospital have my full permission to provide medically necessary treatment, and I agree to assume full financial liability for any and all expenses incurred. I understand that payment is due at the time of service and that I am fully financially responsible for all services rendered. I also agree to pay for all expenses incurred to collect the debt including, but not limited to, attorney fees, collection agency fees, and billing fees.

Best Contact Number*

Signature of Owner / Guardian / Agent:*

DateTime

SURGICAL & ANESTHESIA CONSENT