Surgical Form

1

I have the authority and I authorize the treatment and/or surgery for my pet, Pet's Name * and I am aware of the following:

2

Type of surgery/treatment authorized

3

I have received a written estimate of the costs involved. IT IS ONLY AN ESTIMATE. If further treatment or surgery becomes necessary, the cost will change. I may get an update at any time by calling the office between 9am and 4:30pm. There is no payment plan available within the clinic but we do accept cash, credit cards and checks. All balances are due at the time services are rendered.

Initial

4

There are inherent risks involved with the use of anesthetics. One way to minimize this risk is to make sure there are no problems with internal organs that would compromise anesthetic safety. Pre-surgical blood work is performed to determine if your pet is healthy enough to undergo general anesthesia. Some internal problems are not apparent during a physical examination and may only be detectable when pre-operative blood screens are performed. Anesthesia lowers the blood pressure which could harm internal organs like the liver and kidneys if these organs are not healthy.

I authorize pre-surgical blood work.

I decline pre-surgical blood work and assume any resulting risk.

5

Owner's Initial

6

Intravenous fluids are given when general anesthesia is required to keep the blood flow to the kidneys normal. This is important for animals that are very old, have medical problems and any pet that is dehydrated.

I authorize the use of intravenous fluids during my pet’s surgical procedure/treatment.

I decline the use of intravenous fluids during my pet’s surgical procedure/treatment.

7

Owner's Initial

8

Surgical procedures can be painful. We make every effort to keep your pet comfortable before, during and after surgery/treatment. An injection to alleviate pain after surgery/treatment is strongly recommended. In some cases oral pain relieving medication for owners to give at home will be prescribed.

I authorize the administrations of medication to relieve pain, if needed.

I decline the administrations of medication to relieve pain.

9

Owner's Initial

10

If cardiac and/or respiratory arrest occurs (that is, if a pet stops breathing and/or his/her heart stops beating) then cardiopulmonary resuscitation (CPR) will be performed to revive the pet upon your request.

I authorize CPR to be performed on my pet and I agree to any resulting charge.

I decline CPR to be performed on my pet (DNR) and I understand what this means.

11

Owner's Initial

12

Owner Signature* This field is required.

Clear

13

Date* This field is required.

Date

14

Has your pet ever had any reactions to anesthesia

Yes

No

15

If Yes, Please Specify

When

What was the drug?

16

I authorize the use of appropriate anesthetics and other medications. I have been advised of the nature of the procedure(s) and the risks involved. I realize that results cannot be guaranteed and I assume all risks of anesthesia, surgery and failure to follow post operative care instructions including cage rest and the use of an e-collar. Without an e-collar, your pet is capable of scratching, biting and traumatizing the surgical site impeding recovery and possibly leading to secondary infection and the need for additional surgery at an additional cost to you. An e-collar must be worn until full recovery is achieved and sutures are removed.

17

Signature* This field is required.

Clear

18

Date* This field is required.

Date

19

Email

Best Phone Number to be Reached at

In case of emergency and I cannot be reached please contact ( Name )

In case of emergency and I cannot be reached please contact ( Phone )