Procedural Consent Form

Procedural Consent Form

Thurman Veterinary Center
Please READ this form carefully. If you have any questions about the form, please do not hesitate to call our office.

Please complete 24 hours prior to surgery or we reserve the right to reschedule your pets procedure.
Your pet should not have ANY food after 8pm the night before surgery. Small amounts of water are okay.
Date of procedure*

MonthDayYear
Date
Owner's Name:*
Owner's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner's Date of Birth (this is needed for medications used during surgery)*

MonthDayYear
Date
Pet's Name:*
Sex of pet:*
Age: *
Breed:*
Color:
Dog/Cat:*
Scheduled Procedure:*
Is you pet having a second procedure today, please select the second procedure below:
Example: Spay and Mass removal. Choose Spay on "Surgical Procedure" and Mass removal from this drop down.
If you selected other above, please state surgical procedure being performed today:*
Medications taking:*
Enter N/A or none if pet not taking any medications currently
Pre-Anesthetic Blood Testing: Our greatest concern is the wellbeing of your pet. We will be using pulse oximetry technology to monitor your pet during surgery. This technology along with pre-anesthetic blood screening reduced many of the risks of surgery. Before putting your pet under anesthesia, we recommend pre-anesthetic blood work. Many conditions including disorders of the liver, kidneys and blood many not be detected unless blood testing is performed. For these reasons, we strongly recommend that all patients receive blood work before surgical procedures.

Bloodwork is manditory for patients 7 years of age and older. It will automatically be run.
Based on your pets age, bloodwork is required prior to any surgical procedure.

Yes, my pet will have a blood test performed before anesthesia
Based on your pets age, bloodwork is optional. Would you like this test to be performed today prior to your pets surgical procedure?*

Yes, I want my pet to have a blood test performed before anesthesiaNo, I decline this blood test and have been informed of the risks
Spay Procedure (Female patients only): If your pet is undergoing a spay procedure today, please read carefully. Here are some additional charges you could incur. When a canine/feline is “in heat” their uterus and uterine horns become engorged; thus making surgery time consuming and difficult. If your pet is “in heat”, there will be an extra charge. If your pet is pregnant, you can continue the spay procedure at an extra charge. If you choose to not have your animal spayed while pregnant (which was not detectable until already in surgery), your pet will be sutured and allowed to whelp, but you will still incur the cost of the spay procedure.*

Yes, I have been informed of the extra charges if my pet is “in heat.”Yes, If my pet is pregnant and would like to continue the procedure.No, I would not like my pet spayed if pregnant and will pay the full spay price.
Dental Extractions (Removing teeth)

Due to the increased risk of keeping your pet under anesthesia longer, we cannot call you if extractions are necessary during the dental procedure.
Extractions: If your pet is going to be undergoing a dental, there might be a need to remove loose or infected teeth. These infected teeth will not be removed unless it is determined medically necessary by Dr. Thurman. There is an additional cost to remove.*

Yes, I give permission to extract loose or infected teeth.No, I do not want my pet to have extractions and I understand the risks of leaving the infected teeth.
Mass Removal:
If we are removing a mass on your pet today, would you like the mass sent out for testing to determine what it is?*

Yes, Send my pets mass out for testing with an additional charge ofNo, I decline to have my pets mass tested.
Miscellaneous Services:

While your pet is under anesthesia, we are able to perform many convenient procedures.
Yes, I want my pets nails trimmed.Yes, I want my pets ears cleaned.Yes, I want my pets anal gland expressed.Yes, I want a Microchip placed.Yes, I would like an exam (please select "other" and fill in concerns)Other
Update Vaccinations: Would you like your pets vaccinations updated today?*

Yes. Please update my pets vaccinations. (There will be a list below of vaccinations you would like your pet updated on)No, I decline updating my pets vaccinations at this time
I would like my pets updated on these vaccinations. We will only update your pet on the vaccinations you select (only if they are due at the time of surgery).*

DA2PP: (Annual) Core vaccinationBordetella: (Annual) Core vaccinationRabies: (Given every 3 years after the first year) Core VaccinationInfluenza: (Annual) Only given if pet boards or is around other unfamiliar dogs frequently (dog park)Leptospirosis: (Annual) Given if pet is around wild animals (pet must drink from standing water contaminated with urine of an affected animal). Example: Hiking, live near golf course, dog parkRattlesnake: (Annual) Given if pet goes on hikes or lives in areas where rattlesnakes are present.
I would like my pets updated on these vaccinations. We will only update your pet on the vaccinations you select (only if they are due at the time of surgery).

FVRCP: (Annual) For indoor catsFVRCP/FELV (Annual) For indoor/outdoor catsRabies: (Given every 3 years after the first year) Core Vaccination
Retained Puppy Teeth

A retained or persistent deciduous (baby) tooth is one that is still present despite the eruption of the permanent tooth (between three to seven months of age). This can cause the permanent teeth to erupt in abnormal positions, resulting in an incorrect bite pattern (or how the upper and lower teeth fit together when biting or chewing). Retained deciduous teeth may also cause overcrowding of teeth, accidental bites into the palate, or an abnormal jaw position.

As with most oral issues, early recognition and immediate dental care is essential to prevent permanent damage. Unfortunately, it often goes undiagnosed until later in life.

Retained deciduous teeth are more common in dogs, though it does occur in cats. It often affects smaller breeds of dog, including the Maltese, Poodles, Yorkshire Terriers, and Pomeranian.
After reading the above information and understanding the risks of leaving them. Would you like us to remove your pets retained puppy teeth (If there are not retained teeth you will not be charged)?*

Yes, I want my pets puppy teeth extractedNo, I decline the removal of retained deciduous teeth and understand the health implications.
If your animal is displaying signs of having fleas/ticks/ worms and is found to be carrying them, they will be treated AUTOMATICALLY at a cost to the client. Thank you for understanding.

Pain Management/Antibiotics: During your pets procedure they may receive a pain and/or antibiotic injection. We may send home additional pain medication and/or antibiotics at Dr. Thurman’s discretion. These medications will aid in your pets recovery.

After a dental procedure, your pets’ teeth can be tender and/or they may have gum line recession and/or gum bleeding.
I am the owner or agent, of the pet described above, and has the authority to authorize this consent. I authorize Dr. Thurman and his staff to perform the above named procedures and have been informed of the reasons for the procedures, along with the benefits and risks involved. I understand there are certain risks with anesthesia that could include serious bodily injury or death. These risks are present with any surgical procedure that involves anesthesia. I give my consent to use anesthesia. I also understand there are unforeseen issues that may require extensions of the planned procedure or operation and I authorize the veterinarian to perform these extensions using his/her professional judgment. I have read and understand this consent form. Results cannot be guaranteed and I assume all risks associated with the procedure. I give my consent to the proposed treatments/procedures. Pain management and Elizabeth collars are required for all surgical procedures and understand these fees will be included in the total price. I agree to pay for in full for all the services rendered, on the date of the procedure.
Signature of Owner/Agent*

Clear
Date:*

MonthDayYear
Date
Phone #:*
Alternate Phone #:
On the day of the procedure, a technician will call you when your pet is up from anesthesia and give you an update. Your pet will be available to go home between 3:00pm-4:30pm, unless otherwise instructed.
Please upload photos of any masses to be removed or areas of concern.

Cancelof
Should be Empty:

Procedural Consent Form

Dental Extractions (Removing teeth)

Mass Removal:

Miscellaneous Services: