COMMUNITY SURGERY CONSENT/AUTHORIZATION

PLEASE FILL OUT CHEW's SURGERY CONSENT FORM

I have read and understand the post-surgical instructions emailed to me. I recognize the importance of following these instructions carefully and acknowledge my responsibility in preventing post-operative complications.

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Anesthetic Dental Cleaning. I understand that my pet will undergo general anesthesia for his/her dental cleaning procedure. During the procedure, the teeth will be scaled, assessed, and polished *

If diseased or fractured teeth are found and need to be extracted for the health of the pet, please choose how you would prefer for us to proceed:*

I elect to allow the doctor to remove all affected teeth as needed and understand that I am financially responsible for the cost accruedI request a call from CHEW with a price quote before removing any affected teeth. *I understand that I must be easily reachable via phone throughout the day to allow the medical team to obtain consent prior to extraction while my pet is under anesthesia. If I fail to answer my phone, then affected teeth will be removed by the doctor at owner's expense

If the Veterinarian recommends sending off the mass/growth to pathology:

I understand there will be an additional charge if any of the following conditions: Pregnant or in-heat at the time of the spay, has a hernia, or is cryptorchid. *

I understand an examination with a veterinarian is suggested within 4 weeks prior to any surgery. If the patient has no up-to-date exam, one will be completed the morning of the procedure at owner’s expense. Upon examination and evaluation of any pre-op blood test results, the veterinarian on duty will determine if the patient is a good anesthetic candidate and can undergo the scheduled procedure. *

I understand an IV catheter will be automatically placed in all surgical patients (except for feline neuter patients, or deemed not necessary by the DVM on staff) at no additional charge for administration of IV fluids or for use in the event of an emergency. *

Intravenous Fluids ($15, unless otherwise stated) - The benefits of IV fluids include improved perfusion to tissues, improved intra-op blood pressure, less stress to the kidneys and other internal organs, less risk of complications, and faster recovery. *Intravenous fluids will be given, at owner expense, in all patients over 7 years of age OR if deemed necessary by the veterinarian as a stabilizing or life-saving treatment during surgery. *

24hr PAIN CONTROL - Required for all spays, highly suggested for neuters - ($18) dogs up to 50lbs / ($30) dogs between 50lbs - 74lbs / ($45) over 75lbs) The benefits of the post-op 24 pain injection include decreased pain response intra and post-op (immediately after surgery), decreased inflammation of the surgical site, better pain control and comfort the night after the procedure, and not having to give an oral medication the night of the procedure (which can be difficult due to decreased appetite after anesthesia). *

SCREENING BLOODWORK (1): If your pet is coming in for a Spay/Neuter: Pre-surgical bloodwork is essential for ensuring your pet's safety and the success of the procedure. It provides a comprehensive overview of your pet's health, identifies hidden conditions, and ensures the safe administration of anesthesia. Blood tests can reveal issues such as liver or kidney dysfunction, diabetes, anemia, infections, or electrolyte imbalances. Establishing baseline values helps us monitor changes during and after surgery, promoting a smoother recovery and allowing for timely interventions if needed. This proactive step minimizes risks and optimizes outcomes for your pet. ***ALL patients 7 years old and older, bloodwork is required and must be done PRIOR to the surgery date unless agreed upon by the Director of CHEW. *

Basic ($90) Chemistry10 and CBC or Comprehensive ($145) Chemistry17, CBC and Electrolytes

SCREENING BLOODWORK (2): If your pet is coming in for an Orthopedic Surgery: ALL orthopedic surgeries require pre-surgical bloodwork and must be done PRIOR to the surgery date unless agreed upon by the Director of CHEW. Pre-surgical bloodwork is essential for ensuring your pet's safety and the success of the procedure. It provides a comprehensive overview of your pet's health, identifies hidden conditions, and ensures the safe administration of anesthesia. Blood tests can reveal issues such as liver or kidney dysfunction, diabetes, anemia, infections, or electrolyte imbalances. Establishing baseline values helps us monitor changes during and after surgery, promoting a smoother recovery and allowing for timely interventions if needed. This proactive step minimizes risks and optimizes outcomes for your pet. Pets over 7 years old are required to have the Comprehensive Panel

PARASITES: To prevent spread of parasites in the hospital, any pets with visible fleas will be treated with Capstar, a 24-hour oral parasiticide, at owner's expense. *

CONE ($12): An e-collar (cone) is highly recommended to prevent licking of the incision site, which can lead to severe complications and increased cost, such as infection, opening of the incision site, excessive bleeding, additional anesthesia to repair the incision site, etc. *I understand that I am responsible for preventing post-op complications secondary to licking of the incision site AND that I will be responsible for any professional fees related to necessary repairs from these complications.*

I REQUEST the use of life saving measures, such as medications or CPR (Resuscitation), if my pet suffers complications during anesthesia, including respiratory or cardiac arrest. I understand that my pet may not respond to medications or CPR, or that he/she may respond initially and then suffer another arrest later. I understand that my pet may die despite our live saving measures, and that if he/she survives, there may be permanent complications. I acknowledge and understand that I will be financially responsible for any professional fees related to these emergency treatments. I will NOT hold the team at CHEW Animal Clinic responsible for the passing of my pet in the event of an emergency*

I AGREEI DISAGREE

I DECLINE the use of life saving measuring, including medications or CPR (Resuscitation), if my pet suffers complications during anesthesia, including respiratory or cardiac arrest. I understand that my pet may die without the use of life saving measures. I elect to have DNR (Do Not Resuscitate) orders placed on my pet’s record. I will NOT hold the team at CHEW Animal Clinic responsible for the passing of my pet in the event of an emergency*

I AGREEI DISAGREE

PAY IT FORWARD! Would you consider making a donation today? *this donation will be added to the deposit below*

Help another family with a life-saving surgery! CHEW's Compassion Fund goes directly to a pet in dire need of help. We rely on caring donors to help those in immediate need of life-saving care, surgical intervention, and chronic on-going medical care.

As the owner / agent of Allocated, I authorize the team at CHEW Animal Clinic to perform the procedure(s)/treatment(s) listed above. As with all anesthetic, treatment, and/or surgical procedures, I understand there are risks inherent in these services. I acknowledge that staff members at this practice have explained the procedures to me, answered questions to my satisfaction and cannot be held responsible for any unforeseeable results. Further, I understand that I am financially responsible for all costs incurred from the procedure(s) and treatment(s).

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TO CONFIRM YOUR APPOINTMENT, PLEASE PAY YOUR $50 DEPOSIT. THIS DEPOSIT WILL BE APPLIED TOWARDS YOUR VISIT *

USDA DEPOST OF AT LEAST $50 IS REQUIRED 24 HOURS PRIOR TO YOUR APPOINTMENT

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