Veterinary Emergency Surgery Consent Form
Surgical Procedure
Date of Surgery
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Month
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Day
Year
Date
Pet Information
Name of the Pet
Age
Date of Birth
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Month
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Day
Year
Date
Sex
Breed
Color
Current Medications which includes supplements
Owner Information
Name of the Owner
First Name
Last Name
Phone Number
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Area Code
Phone Number
Email Address
example@example.com
Hospital Information
My pet's hospital name:
My pet's primary care veterinarian:
Anesthestic Risk:
Every effort will be make to make anesthesia as safe as possible; however, anesthesia has inherent risks. The incidence of complication from anesthesia are extremely low and PPSC or your veterinarian does not anticipate any in your pet. However, on rare occasions the following may occur including - but not limited to: 1) allergic reaction the anesthetic agent 2) abnormal heart rhythm 3) changes to blood pressure 4) respiratory difficulty 5) aspiration pneumonia or gastroesophageal regurgitation 6) death
Surgical Risks:
1) Infection which may require additional testing and medication at an additional cost. 2) Blood clots that can lodge in major organs causes stroke, shortness of breath, and/or death (i.e. thromboembolism) 3) Postoperative swelling or edema 4) Risks pertaining to gastrointestinal (GI) surgery - Dehiscence or abnormal healing of the GI tract is possible. If dehisence occurs, it is generally 3-5 days following surgery. This is a life-threatening complication and is an emergency. 5) Risks pertaining to mass or cancer removal - There are several possibilities that can occur and include recurrence or regrowth of the mass, development of new masses, development of a post-surgical wound from abnormal healing, or identification of spread of the cancer to other areas of the body following surgery.
Use of Nocita: Nocita (bupivacaine liposome injectable suspension) is a long-acting, local anesthetic that provides up to 72 hours of post-operative pain relief by releasing bupivacaine (anesthetic pain relief agent) over time. PPSC can provide this additional form of pain medication during surgery for your pet if you would like to do so. Nocita is labeled for single-dose infiltration into the surgical site to provide local post-operative analgesia for cranial cruciate surgery in dogs and a nerve block in cats for declaw procedures. However, I offer Nocita for pain control in other surgeries when it is safe to do so (abdominal surgery, chest surgery, and/or amputation). This is an off-label use of the medication, as it has not be approved to be used in this specific way. May PPSC use this medication (Nocita) when it is safe to do so for your pet?
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Yes - I approve use of Nocita and understand that it will be used in select cases and only when deemed safe to do so. I also understand that it is an additional charge to my pet's surgery fee.
No - I do not approve the use of Nocita in my pet.
At time to time, PPSC will post on social media (Facebook, Instagram, etc..). With your permission, we may share your pet's picture, video or story. We may mention your pet by name, but never the owner's name. Do your consent to use this information on social media or our website (www.pricklypearsurgery.com)?
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Yes
No
Cancellation policy:
There is a $350 cancellation fee if your pet's surgery is canceled after completing this form.
Authorization and Consent
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I am authorized to make a decision and sign this consent.
I have been explained the surgical procedure including the risks, complications, and anticipated recovery.
I hereby authorize the admitting veterinarian (and his/her/their designated associates or assistants) to administer treatment as is necessary to perform the aforementioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to the results or cure.
I understand that following surgery the admitting veterinarian and staff will be responsible for my pet's recovery from anesthesia and any additional care.
Pet Owner Signature
Signed Date
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Month
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Day
Year
Date
Submit
Should be Empty: