Lake Seminole - Surgical Consent Form

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Surgical Consent Form* This field is required.
Owner Name
Email
Phone
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Pet Information* This field is required.
Pet Name
Breed
Sex
Procedure
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CONSENT FOR SURGERY & TREATMENT WITH SEDATION OR ANESTHESIA
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Food to be withheld after 9:00 pm?(does not apply to rabbits, rats, and other pocket pets)
Yes
No
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Any medications given this morning?
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PRESURGICAL SCREENING & DIAGNOSTICS
My pet is less than 7 years old and has a routine medical history
Recommended basic pre surgical bloodwork is PCV (checks for anemia), CT (measures the blood's ability to clot) and a Minor Chemistry Screen (checks liver, kidney, and protein levels)
Declined recommended profile: consent for minimum required for screening only PCV/CT/AZO
My pet is 7 years orolder OR has a compromised medical history
Recommended comprehensive pre-surgical bloodwork is CBC (complete blood count measures types of red/white blood cells and platelets), CT (clotting time of blood) and Full Chemistry Screen (checks liver, kidney, protein levels, pancreas, and electrolytes) Done
Minimum required screening level PCV, CT, Minor Chemistry Screen
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OTHER RECOMMENDATIONS:

    Buccal Mucosa Bleeding time (BM/BT) REQUIRED for Rottweilers and Dobermans.
    **important for certain breeds of dogs common to have bleeding disorders
BREED SPECIFIC RECOMMENDATIONS
DOGS: Airedale Terrier, Akita, Basset Hound, Bernese Mountain dog, Boxer, Chesapeake Bay Retriever, Dachshund, Doberman, German Shepherd, German Shorthair Pointer, German Wirehair Pointer, Golden Retriever, Greyhound, Irish Wolfhound, Keeshond, Kookier, Manchester Terrier, Miniature Poodle, Miniature Schnauzer, Pembroke Welsh Corgi, Pit Bull, Rottweiler, Shetland Sheep dog, Scottish Terrier, Standard Poodle

Pre-anesthetic ECG (electrocardiogram measures heart electrical function prior to anesthesia)
    **important for pets over the age of 7 years old and certain breeds of cats and dogs to heart muscle problems
    BREED SPECIFIC RECOMMENDATIONS
    CATS: Persian, Maine Coon
    Dogs:  Airedale, Boxer, Cocker Spaniel (American), Cocker Spaniel (English), Dalmatian, Doberman Pincher, Golden Retriever, Great Dane, Irish Wolfhound, Newfoundland, Old English Sheepdog, Portuguese Water dog, Standard Poodle

Microchip (injection to implant permanent identification)
   **The microchip is implanted near the shoulder. A unique serial number on the chip allows your pet to be identified if lost, stolen or injured. The number will be listed to Lake Seminole Animal Hospital unless you register the microchip to yourself.

Laser Therapy Laser therapy as part of post operative pain management, helps reduce inflammation at the surgery site and speeds the healing process.
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PET OWNER'S INFORMATION
Your pet will be given medication to ease any discomfort during recovery. Your pet may be given additional medications which will be sent home after surgery. These will be explained to you at your pet's discharge appointment.
Part of preparation for surgery or treatment may involve shaving fur from the affected area of your pet's body. This is not grooming. We may also shave small area from the legs or other locations for placement of an I.V. Catheter, ease of administration of medications, or collection of blood samples if needed.
If determined as needed, your pet's toenails will be trimmed as a courtesy service while under sedation. Newly trimmed nails are sharp and may scratch you.
DOGS musthave a current history of heartworm prevention and annual heartworm disease blood test.
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CONTACT INFORMATION:
Who/where are we calling?
DISCHARGE APPOINTMENTTIME
Please Select
Please Select
Yes
No
Would you like to receive text updates about your pet during the day?
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If yes, what number can you receive the text messages?
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Would you allow us to post cute pictures of your pet on our Facebook page or our website?* This field is required.
Yes
No
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I am the owner or agent for the above described pet. I authorize Lake Seminole Animal Hospital to anesthetize/sedate and perform the services described. If requested, I have received an estimate that has been explained to my satisfaction. I accept all procedures done to be to the best of the abilities of the professional staff, and I realize that no guarantee nor warranty can ethically or professionally be made regarding the results or cure. I authorize Lake Seminole Animal Hospital to provide veterinary services as requested or, in an emergency circumstance, to follow through with necessary treatment for the well-being of my pet until further advised. I understand my financial responsibility for all services rendered. I have read, understood, and agreed to authorize this consent by signing below.
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Signature* This field is required.
Clear
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Printed name of person admitting
Should be Empty: