Surgical/Procedure Consent

Surgical Consent
Patient Full Name*
Please enter first and last name (ie Fluffy Smith)
I hereby consent and authorize the following procedure(s) be performed:*

Canine SpayCanine NeuterFeline SpayFeline NeuterMass RemovalDentalMass Removal and DentalMass Removal and Spay/NeuterOther
If you chose other, Please specify what procedure will be performed. *
Wellness Exam - Before undergoing any anesthesia, the doctor will perform an exam to assess the patient's physical condition.*

I acknowledge that an exam fee will be charged if the procedure is not performed within 2 weeks of a prior wellness examination or first available appointment if not able to book within the 2 week window.
Dental Procedure - base price $361.62

What is included:
- Under general anesthesia, plaque is separated from teeth using an ultrasonic scaling instrument, and then lightly polished for a smooth surface before a fluoride treatment is administered. The doctor will examine the entire mouth and check for dental problems.
- Blood Work is recommended prior to undergoing anesthesia to detect internal issues that may not be readily evident upon physical examination. If adequate blood work was done in within 90 days, $30 will be subtracted from your total. Annual Heartworm test must be current. This can be done for an additional fee of $46.55 - $62.69.
- IV Fluid Therapy is important to the maintenance of homeostasis during anesthesia and provides venous access for supportive therapy, for maintenance of anesthesia, and for cardiopulmonary resuscitation. Imbalances may occur because of blood loss, drying of exposed tissues, and low blood pressure effects of some anesthetic agents. There will be a small shaved portion on your pet's leg.
- Full Mouth Radiography involves obtaining X-ray images of the mouth, teeth, and jaws. Radiography is painless, safe, and completely noninvasive. The doctor can identify problem teeth or other issues that may need to be addressed during the dental, and after tooth extractions to confirm that all the tooth roots have been removed.
- Full Mouth Laser Therapy helps to aid in the healing of tissues of the mouth following scaling, probing, and extractions. Therapy lasers help to reduce pain, minimize swelling and increase the speed which the mouth heals.
What May Be Needed:
- Surgical Extraction is necessary to remove dental defects, injury, tumors, cysts, cancer and periodontal infection. Extractions are priced by the hour, with one hour equaling $785.58.
- Medication for pain control and/or antibiotics will be discussed by the doctor and dispensed if necessary $26-80.
Dental Continued: Jelsema Veterinary Clinic will contact you via telephone at the number indicated at the bottom of this form. If Surgical Extractions are recommended and the doctor is unable to reach you via your provided contact information please indicate your wishes regarding proceeding with surgical services.*

Yes, Please proceed with surgical recommendations if you are unable to reach me.No, No not proceed with surgical recommendations if you are unable to reach me.
Mass Removal: We ask owners to do their best to locate and identify masses or growths that they wish to have removed while your pet is anesthetized. If spots are small or not obvious, please mark them on your pet to your best ability.
Blood Work prior to undergoing anesthesia is recommended to detect internal issues that may not be readily evident upon physical examination. The cost is $58.88. This screen is required on all dogs less than 10 pounds and all animals 8 years of age and over.*

Yes, I do want the blood screen. (Doctor's recommendation)No, I do not want the blood screen.
IV Fluid Therapy is important to the maintenance of homeostasis during anesthesia and provides venous access for supportive therapy, for maintenance of anesthesia, and for cardiopulmonary resuscitation. Imbalances may occur because of blood loss, drying of exposed tissues, and low blood pressure effects of some anesthetic agents. The cost is $44.49 and there will be a small shaved portion on your pet's leg. Fluids are required on all dogs less than 10 pounds and all pets 8 years of age and over*

Yes, I want my pet to have fluids during surgery. (Doctor's recommendation)No, I decline fluid therapy
Histopathology- Sometimes samples or biopsies are recommended to be submitted for further evaluation at a diagnostic laboratory. There, a veterinary pathologist will examine the sample and make a diagnosis. Results are generally available within 5-7 business days. The cost for this is $173.98. Additional fees would be incurred for large or bony samples. If the doctor recommends histopath, would you like us to submit your pets sample?*

Yes, submit the sample (doctor's recommendation)No, I would not like the sample submitted
E-Collar and Protective Apparel- Pets that lick or bite at the surgery site will go home with an E-Collar for their protection. Some pets will ignore the site until many hours after they are discharged from the clinic. For this reason, we recommend you consider purchasing one before you leave to avoid the cost of Emergency Care.*

Yes, I would like a classic e-Collar. $13.00Yes, I would like an inflatable e-collar. (if applicable) $25-$47Yes, I would like a VetSuit Recovery Suit. $37 - $52No, I do not want an e-collar.
Pain Management and Antibiotics Our staff not only cares about the care your pet receives at our clinic, but also the comfort they are in at home, for this reason, we require pain relief with all surgeries. Medications will be given during the procedure via injection as well as sending an oral formulation home with your pet following surgery. Antibiotics will be discussed by the doctor, and dispensed if necessary.*

I acknowledge that pain medicine will be administered to my pet during surgery and additional medication may be sent home for continued post-operative therapy.
Laser Therapy During Procedures: K-Laser Therapy, infrared laser light improves the healing process. It increases the release of endorphins (natural painkillers), decreases inflammation, which helps return tissue to a normal state, and restores metabolic function. This is included in all surgeries.*

I acknowledge that use of a Class IV Therapeutic Laser may be administered on my pet following surgery.
Additional Services

The following are additional services that may be performed while your pet is under our care. An estimate can be provided at your request.
Vaccines: Your pet may be due for vaccines or will be due in the near future.

Yes update all vaccinesNo, do not update vaccinesIf you prefer to separate vaccines, please list which vaccines you prefer today.No vaccines are requested at this time.
Flea/Tick Prevention

Vectra 3D (Monthly topical- Canine only)Nexgard (Monthly oral chew- Canine only)Seresto Collar- fitted to your pet (Every 6- 8 months Collar-Canine or Feline)Catego (Monthly topical- Feline only)Revolution (Monthly topical- Feline only Canine available via Vetsource online pharmacy)No Prevention requested at this time.
Heartworm Prevention

ProHeart 6 (Injectable- Every 6 months Canine only)ProHeart12 (Injectable- Every 12 months Canine only)Interceptor Plus (Monthly oral chew- Canine only)Heartgard Plus (Monthly oral chew- Canine only)Revolution (Topical- Feline any size and Dogs under 5 lbs)No Prevention requested at this time.
Other Services

Microchip Implant and Registrations $53.82 (Includes lifetime registration)Anal Gland Expression $20.17Nail Trim (routinely performed while under anesthesia- this is complementary)Do not trim nails (we will forgo the nail trim if you choose this option)
CPR or DNR Consent Form
DNR means “do not resuscitate”. This is a decision that resuscitation (CPR) is not to be performed in the event that the pet stops breathing, has no heartbeat, collapses or becomes unconscious. Resuscitation (CPR) of a collapsed or unconscious patient is tailored to meet the needs of the individual but may include any or all of the following: •Establishing an airway via insertion of an endotracheal tube and administration of oxygen or medications through the tube •Establishing intravenous access via insertion of an intravenous catheter and administration of fluids and injectable medications through the catheter•Chest compressions •Intracardiac delivery of injectable medications, Animals that have survived cardiopulmonary arrest and have been successfully resuscitated (CPR) are extremely critical and unstable. Management of the post-arrest patient requires vigilant monitoring and the technical expertise of dedicated critical care personnel. This care is costly and the outcome is uncertain.I have read and understood the information above or have had it explained to my satisfaction. I understand that the anesthetic, surgical or therapeutic procedures and treatments my pet is undergoing today may involve the risk of complications, injury or even death, from both known and unknown causes and no warranty or guarantee has either been expressed or implied as to the result or cure. Hereby, I expressly agree to release Jelsema Veterinary Clinic, and its agents and representatives, from liability for any and all damages to my pet and agree to hold JVC, its agents and representatives harmless from any liability (except in the case of gross negligence) associated with the procedure and treatments being performed on my pet*

DNR I DO NOT wish the staff to perform CPR on my pet. I understand that if my pet suffers from cardiac arrest, respiratory arrest, collapse or unconsciousness if CPR is not performed, my pet will pass awayCPR I wish the staff to perform resuscitation (CPR) on my pet if my pet suffers from cardiac arrest, respiratory arrest, collapse or unconsciousness.
I have chosen the DNR option. I agree to pay fees for veterinary services and products incurred for my pet which were previously agreed upon. *
Please type your name or initials in the box
I accept that if the hospital staff is unable to reach me within 20 minutes after the initial CPR procedures, and after exercising reasonable medical judgment, determine that there is no hope for success, the staff will cease further CPR procedures. I understand that despite the best effort of the veterinarians and staff at this facility, even the most successful CPR that may restore my pet’s life may not allow for my pet to regain his/her normal mental and physical health.*
Please type your name or initials in the box
I agree to be held financially responsible for veterinary services provided to my pet while staff members pursue treatment and try to reach me for further directions. Regardless of my pet’s recovery or survival, I agree to pay CPR fees in addition to other fees already identified by the practice and agreed upon by me.*
Please type your name or initials in the box
I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) than those set forth above. Therefore, I hereby consent to authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarian's professional judgment. I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. I have been advised as to the nature of the procedures or operations and the risks involved. I realize that results cannot be guaranteed. It is the client's responsibility to pay for all medical visits or office procedures done at Jelsema Veterinary Clinic at the time of service. A late fee of $5.00/month plus 22% interest charged per month on all unpaid balances and fees that have not been paid within 30 days. After 90 days of non-payment, the bill will be turned over to collections.
I certify that I am at least 18 years old and authorized to sign on behalf of the patient/client for Jelsema Veterinary Clinic. I have read and understand this authorization/consent and will be responsible for payment for services rendered. Please sign your name on the line below with your finger or stylet (if on a mobile device) or by using the mouse the signature line (if using a PC)*

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Phone number where you may be reached the day of your appointment*
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Surgical Consent

Additional Services

CPR or DNR Consent Form