St. Francis - Anesthetic Procedure Consent Form

Anesthetic Procedure Consent Form
Name*

First NameLast Name
Pronouns

She/HerHe/HimThey/ThemOther (write your pronouns here)
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
It is VERY IMPORTANT that we can reach you at this number while your pet is with us!
Preferred means of contact during and after surgery:*

Phone call at the number listed aboveText message at the number listed above (**please note that we may still elect to call instead of text if the doctor needs to have a more extensive conversation with you**)Other (please specify)
Will someone other than the above named person be dropping your pet off for surgery? If yes, what is their name and are they authorized to give consent on your behalf?*
Will you be dropping off your pet for surgery?

Yes, I will be dropping off my pet for surgery.No, someone else will be dropping off my pet for surgery.
What is the name of the person who will be dropping off your pet?
Does this person have your permission to consent to any additional diagnostics or procedures beyond what is covered in this form?

Yes, they have my permission to consent.No, they do not have my permission. Please contact me to discuss anything additional that might require consent.
Patient Information
Pet's Name*
Species*

CanineFelineOther
Birth Date or Estimated Age*
Breed*
Color*
Sex*

Male, unneuteredMale, neuteredFemale, unspayedFemale, spayedI don't know my pet's sex.
What were the start and end dates of {petsName13}'s most recent heat cycle?
Approximate dates are okay
Procedure Information
Scheduled Date of Anesthetic Procedure*

MonthDayYear
Date
Pre-Surgical Preparation
The Night Prior to Surgery/Dentistry

Dogs and Cats: Withhold all food and treats after 10 pm. Your pet should not receive any breakfast or treats on the morning of surgery. Your pet must be fasted. You may still allow access to water.

Small Mammals: If your ferret, rabbit, or rodent is scheduled for surgery, do not withhold food or water unless instructed by the doctor.

The Morning Of Surgery/Dentistry

If your dog or cat has accidentally received any food or treats, please inform us. This can lead to anesthetic complications.

Medications or Supplements:

Most pets will receive an analgesic (pain medication) prior to or during surgery. Please do not ever give your pet over-the-counter pain medications such as aspirin, Tylenol, or ibuprofen. Some of these may cause post-surgical bleeding problems, while others can cause fatal liver or kidney disease.

If your pet is on any daily medications, please call us in advance to discuss whether these should be given on the day of surgery. When in doubt, please withhold morning doses of medications unless otherwise instructed. All herbal therapy should be discontinued three days prior to any surgical or dental procedure.

Checking in:

Please arrive for surgery check-in and drop off at 8:00am and allow 15-20 minutes to be checked in. What time your pet can go home varies depending on what procedure is being performed and when your pet's procedure begins. Most pets are discharged between 4 pm and 6 pm. If you have specific time constraints with regards to when you need to pick your pet up, please let us know as soon as possible so that we can try to meet your needs.
List all medications and/or supplements that {petsName13} is currently taking:*
Surgery check-in time is at 8 am. Most pets are ready to be discharged between 4 pm and 6 pm. Do you have any time constraints with regards to {petsName13}'s check-in or discharge time? *
{petsName13} is having a: (choose all that apply)*

Spay or neuter procedureMass removalCystotomy (bladder surgery)Enucleation (eye removal)Amputation (limb, toe, or tail)GastropexyDental cleaning, with or without extractionsOral mass removalOrthopedic surgery (fracture repair, cruciate ligament repair)Other
Spay/Neuter Procedure
What is a spay or neuter?

A spay (ovariohysterectomy- removal of the ovaries and uterus) or neuter (orchiectomy- removal of the testicles) is a surgical procedure that eliminates the possibility of reproduction. These procedures also eliminate or reduce the risk of certain diseases, such as pyometra (infection of the uterus), uterine cancer, testicular cancer, and mammary cancer.

How is a spay or neuter performed?

During this procedure, your pet will be anesthetized. The abdomen is shaved and cleaned, and an incision is made into the abdomen. The ovaries are located and freed from the surrounding tissues, and the blood vessels to the ovaries are tied off with sutures. The blood supply to the uterus is also located and tied off with sutures, and the uterus and ovaries are removed. The incision is closed in multiple layers with suture. Pain medication will be given during the procedure, and additional pain medication may be given after the procedure depending on your pet’s needs. Pain medication is sent home to make your pet more comfortable over the next few days as your pet recovers from surgery.

What are the potential risks of a spay or neuter?

Spay and neuter procedures are considered routine surgeries, and the overall risk is low. Nevertheless, it is a significant operation and as such, it requires careful aftercare, even in pets that seem to recover quickly. Complications related to surgery are not common but can include excessive bleeding, bruising, and infection. After spay procedures or abdominal cryptorchid neuter procedures, there is a very low risk that abdominal organs could herniate, or protrude, past the abdominal muscles or even through the skin. It is important to follow post-operative instructions to restrict activity and prevent your dog from licking at the incision to lower the risk of these complications. Other surgical complications are possible, but uncommon.
Mass Removal
What is a mass removal?

A mass removal is the surgical removal of a tumor (abnormal growth of tissue). This procedure can sometimes be curative if the entire mass is removed. This procedure can also be used to diagnose what type of tumor a pet has because the mass can be sent to the lab for histopathology (biopsy).

How is a mass removal performed?

During this procedure, your pet will be anesthetized. The surgical site is shaved and cleaned, and an incision is made into the skin to allow removal of the mass. The incision is closed with multiple layers of suture, and depending on the surgeon’s preference, surgical staples or skin glue may be used. Pain medication will be given during the procedure, and additional pain medication will be given after the procedure depending on your pet’s needs.

What are the potential risks of a mass removal?

A mass removal is considered a routine surgery, and the overall risk is low. Complications during surgery are rare and usually related to the use of general anesthesia. After surgery, complications may include excessive bleeding, bruising, infection, or opening of the incision site (dehiscence). It is important to follow postoperative instructions to restrict activity and prevent your pet from licking at the incision to lower the risk of these complications.
Cystotomy
What is a cystotomy?

A cystotomy is a surgical operation that involves opening the urinary bladder. It allows for some or all of the following: removal of urinary calculi (bladder stones) that pose the risk of urinary obstruction, identification and biopsy of masses within the urinary bladder, and/or to obtain culture samples to target antibiotic therapy for chronic bladder infection.

How is a cystotomy performed?

While under general anesthesia, your pet will have hair shaved from his/her abdomen (belly) and the skin will be prepared for sterile surgery. An incision will be made into the abdomen, and the urinary bladder will be identified. The surgeon will make an incision into the urinary bladder and evaluate the inside surface. If bladder stones are present, they will be removed and submitted for analysis as well as culture. A sample of the urinary bladder wall may be obtained for biopsy and/or culture. The urinary bladder will then be closed with suture and evaluated to ensure no urine leakage. The abdomen will be flushed with sterile saline, and the abdominal incision will be closed with multiple layers of suture. Following surgery, your pet will be monitored in hospital for postoperative complications.

What are the potential risks of a cystotomy?

The risks of a cystotomy are those associated any surgery, including bleeding and postoperative pain. Additionally, there is the risk of urinary leakage (uroabdomen), seroma (fluid-filled pocket around incision), infection, and dehiscence (opening of incision). There is also the chance of recurrence of clinical signs, despite appropriate therapy. Finally, there is a risk that we may not identify the specific cause of your pet’s illness and/or be able to fix the underlying problem, despite performing a cystotomy.
Enucleation (eye removal)
What is an enucleation?

The goal of enucleation is to remove a diseased or damaged globe
(eyeball) as well as the 3rd eyelid and the eyelid margin. Usually, the procedure is performed to resolve pain that can be caused by severe ulceration of the eye, glaucoma, trauma to the eye, or other causes. Sometimes, the procedure is performed to remove cancerous tissue or tissue that harbors an infection that cannot otherwise be resolved.

How is an enucleation performed?

Your pet will be placed under general anesthesia, and hair will be clipped from his/her face around the affected eye. The surgeon will remove the globe (eyeball) as well as the surrounding tissues, closing the eyelids permanently with stitches. Following surgery, your pet will be monitored closely in hospital for postoperative complications, and an Elizabethan collar (cone) will be placed to minimize the risk of him/her scratching at the surgery site. Sutures may need to be removed in 10-14 days.

What are the potential risks of an enucleation?

The most common risks of enucleation include bleeding and infection. If all of the tissue around the eye cannot be removed, there is a risk of continued secretions of tears. Draining tracts can also develop with retained tissue. Other risks include those associated with general anesthesia, as well as general risks of surgery, including postoperative infection and/or pain. Additionally, there is the risk of seroma (fluid-filled pocket around incision) formation and dehiscence (opening of incision). There is also the risk that we may not identify the specific cause of your pet’s illness and/or be able to fix the underlying problem, despite performing an enucleation. In some conditions, the underlying disease process can affect the other eye as well, either now or at a future date.
Amputation (limb, toe, tail)
What is an amputation?

Amputation involves the permanent removal of an injured or diseased limb, digit (toe), or tail. The procedure should provide animals with improved comfort. Most dogs and cats adapt very well to life following an amputation.

How is an amputation performed?

Your pet will have the hair clipped from the body part that is to be removed. Under anesthesia, the limb, digit, or tail will be surgically removed, and the surgical incision will be closed using multiple layers of sutures or skin staples. After surgery, your pet will need to wear an Elizabethan collar (E-collar) for 10-14 days to allow the surgical incision to heal. Your pet’s activity will be restricted during this time in order to minimize the risk of complications. Following a limb amputation, many dogs will need to be supported with a sling in the initial period or recovery, as s/he learns to walk on three legs. For at least several days after the surgery, your pet will be given analgesic drugs to control any associated pain. Once the site of the surgery is healed in about 2 weeks, the sutures or skin staples may need to be removed.

What are the potential risks of an amputation?

For healthy animals, amputation is generally a safe procedure. Animals with other illnesses or injury are more likely to have some complications. With any surgery, there is a risk of bleeding and postoperative pain. Additionally, there is the risk of seroma (fluid-filled pocket around incision), infection of the surgical site, and dehiscence (opening of incision). Amputation of a leg, digit, or tail with cancer may or may not cure the cancer. Regardless, the amputation procedure will usually remove a source of pain and make the pet more comfortable.
Gastropexy
What is a gastropexy?

Gastropexy is a surgical procedure to “tack” the stomach in place within the abdomen to prevent it from moving or rotating. This is ideally performed as a preventative, elective procedure to decrease risk of future bloat and stomach displacement or twisting (gastric dilation and volvulus, or GDV). Often, preventive gastropexy is recommended for dogs of predisposed breeds at the same time as a neuter surgery (spay or castration). For dogs that do develop a bloated and twisted stomach, gastropexy is performed as a part of a corrective and life-saving surgery; the intent is that the gastropexy will prevent the same problem from occurring again.

The stomach is the part of the gastrointestinal tract that is between the esophagus and the small intestines, in the front part of the abdomen near the ribs. It is loosely held in place by connective tissue and ligaments, which function to help keep the stomach in the right position and orientation. In some disorders, such as gastric dilation and volvulus; the stomach fills with gas and flips over on itself. This abnormal positioning prevents gas from moving through the stomach and cuts off blood supply to the rest of the body; this is a life-threatening emergency that requires immediate surgery. Certain breeds of dogs, particularly large breeds with deep chests such as Great Danes, Doberman pinschers, German shepherds, poodles, and golden or Labrador retrievers, are predisposed to developing this condition.

How is a gastropexy performed?

During gastropexy, the stomach is surgically attached to the inside of the body wall. This is generally accomplished through making a surgical incision into the abdominal cavity and suturing the wall of the stomach to the inside of the abdominal muscles.

What are the potential risks of a gastropexy?

The most common risks with the surgery include bleeding, infection, anesthetic risk, or breakdown of the sutures, requiring a second surgery. Pets may develop abnormal heart rhythms after surgery, particularly if the gastropexy is done to fix a GDV. Minor complications include stomach upset, diarrhea, and postoperative pain. Very rarely, gastropexy can cause abnormal stomach emptying that might result in vomiting. Failure of the tacking procedure resulting in recurrence of stomach twisting, while uncommon, is possible.
Dental Cleaning, With or Without Extractions
What are dental extractions?

The goal of dental extractions is to remove teeth that may be dead, infected, unstable, broken, or causing pain to your pet. This is performed under general anesthesia, often at the same time as a dental cleaning. Many pet owners do not recognize signs that their pet has mouth pain from dental disease, but after diseased teeth are removed, the pet’s level of comfort will be improved as will their overall oral health. Though some pets may require soft food for a few days after teeth are removed and while the gums heal, most pets have no problem quickly returning to their normal diet. This is true even when all of the teeth must be removed. In fact, your pet might have less pain while eating soon after the bad teeth are pulled than they did just before!

How are dental extractions performed?

Teeth that need to be removed are identified during an initial evaluation of your pet’s mouth while he or she is under general anesthesia. Dental x-rays will help to identify teeth that appear healthy on the outside but are diseased below the gums. A numbing medication may be administered during anesthesia to help minimize pain associated with the removal of teeth even after the pet wakes up from anesthesia. During anesthesia, and after diseased teeth have been identified, they will be extracted. Some teeth can be removed after they are manually loosened from their attachments to the mouth. Other teeth may require more advanced techniques to allow precise, safe removal of the entire tooth. Such techniques include the removal of bone from around the tooth’s root to ensure that the tooth’s root can be clearly seen and fully removed. This is critical to ensuring the most successful outcome to your pet’s dental extractions. Once the tooth has been removed, the location will be cleaned out and smoothed and then sutured (stitched) closed to help your pet’s mouth heal. These sutures will dissolve with time so they don’t need to be removed later on. In most cases, pain control medications are prescribed to use for several days after the extraction to be sure that your pet remains pain free.

What are the potential risks of dental extractions?

Once a tooth is removed, the gums will be stitched closed to help the area heal. There is a possibility that the suture may become loose or fall out prematurely, which can result in delayed healing as well as discomfort. It is possible for a portion of a tooth’s root to break off during extraction, which can cause infection or pain. Dental x-rays after extractions can prevent this outcome by making sure that there are no root fragments left in the mouth. There is a risk of neighboring teeth becoming damaged during the extraction process, and on occasion this may necessitate their removal as well. If there was significant dental disease present before the extraction, it may have caused bone loss and weakening of the jaw. Removal of a tooth in a severely affected area could result in a jaw fracture. There is a small risk of significant bleeding associated with tooth removal. Another uncommon complication that can occur during the tooth removal process is that a tooth is pushed into another area (such as into the inside of the nose) where it can be very difficult to remove.
Oral Mass Removal
Oral Mass Removal: Oral masses are typically removed under anesthesia. A numbing medication may be administered during anesthesia to help minimize pain associated with mass removal even after the pet wakes up from anesthesia. During anesthesia, the mass will be surgically removed. Depending on the size and location of the mass, the tissue will then sutured (stitched) closed to help your pet’s mouth heal. These sutures will dissolve with time so they don’t need to be removed later on. In most cases, pain control medications are prescribed to use for several days after the mass removal to be sure that your pet remains pain free. We advise feeding softened or canned food for 7 to 10 days following an oral mass removal for comfort.
Orthopedic Surgery (fracture repair, cruciate ligament repair)
Orthopedic surgeries at St. Francis are performed by board-certified veterinary surgeons. These surgeons provide detailed information about the procedures that they perform, including aftercare instructions. Please let us know if you have not received this information prior to your pet's surgery.
To protect the surgical site, {petsName13} may need an E-collar (cone) or a surgical suit. Which option would you prefer we send home with your pet?*

E-collar ($15-$20)Surgical suit ($20-$30)I already have an e-collar or surgical suit for my pet (*please be sure to bring this with so we can place it on your pet prior to discharge*)
Deciduous (baby) teeth should fall out by 6 months of age in most pets. If we identify retained deciduous teeth, we recommend extracting them to prevent crowding and premature disease of the adult teeth. If {petsName13} is found to have retained deciduous teeth, would you like us to remove them during this anesthetic procedure? Cost for this ranges from $50 to $200 depending on the number of teeth and difficulty of extraction.*

Yes, proceed with any recommended extractions.No, do not perform any dental extractions.I would like a call to discuss next steps if it is found that my pet has retained deciduous teeth on their pre-surgical exam.This is not applicable to my pet.
Draw an X on the location of the mass(es) to be removed:
Draw an X on the location of the mass(es) to be removed:
We recommend sending masses or abnormal tissues/organs out to the lab for histopathology (biopsy). This test can help us to determine your pet's long-term prognosis and whether there is any recommended followup after surgery, such as a consultation with an oncologist. Cost for this is $190 for one mass. Would you like us to submit {petsName13}'s samples for biopsy?*

Yes, please submit the sample(s).No, I decline to have my pet's sample(s) biopsied.I need more information and would like to discuss this with the veterinarian following surgery.
Unanticipated extractions: In some patients, we encounter unanticipated dental disease (i.e. fractured teeth, abscessed teeth) during the course of the exam and radiographs performed while a pet is under anesthesia. The doctor will call you while {petsName13} is under anesthesia to discuss any unexpected findings and their recommendations. If the doctor discovers teeth that they recommend be extracted, and if we cannot reach you when we try to call you, how would you like us to proceed?*

Do not proceed with any unanticipated extractions. I understand that any additional extractions would need to be performed during a separate anesthetic procedure at a later date.Please proceed with any extractions the doctor deems medically warranted.Other
If {petsName13} has oral surgery (dental extractions or an oral mass removal), we recommend feeding canned food or softening their dry food with warm water for 7 days following their dental procedure. This precaution prevents damage to any sutures or incisions that are present in the mouth. We also STRONGLY advise against feeding a raw diet while pets are healing from oral surgery, as the bacteria within raw foods can cause infection of the surgical site(s). We have canned food available for purchase if needed. Would you like us to send home canned food with {petsName13}?*

Yes, I would like to purchase canned food from St. Francis.No, I don't need any canned food.
Cold laser therapy is a treatment that helps to promote wound healing and provides pain relief. If {petsName13} has a surgical incision or dental extractions, would you like us to perform a laser therapy treatment on those sites today? Cost for this treatment is $25.00.*

YesNo
A microchip is a tiny, rice-grain sized implant that goes under the surface of your pet's skin using a needle. The microchip has a unique number that can be read by a special scanner. While collars can come off and ID tags can get lost, a microchip is a permanent form of identification. If {petsName13} gets separated from you and is found, animal control or veterinary clinics can scan your pet's microchip, and the number is used to look up your contact information. Would you like us to implant a microchip while {petsName13} is under anesthesia? Cost for this procedure is $62.00.*

YesNoI don't know if my pet is microchipped. Please place a microchip if my pet does not already have one.My pet has a microchip, but please scan it to ensure it is working and confirm their number.Other
Please confirm the contact information that you would like associated with {petsName13}'s microchip.

Use the same information provided at the top of this form.Use a different owner name, phone number, email address, and/or address than was provided at the top of this form (please list these below):
Owner's name for {petsName13}'s microchip registration:

First NameLast Name
Phone Number for {petsName13}'s microchip registration:
Please enter a valid phone number.
Email for {petsName13}'s microchip registration:
example@example.com
Address for {petsName13}'s microchip registration:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like to address any preventative care needs (i.e. vaccines, refills of preventative medications, refills of other medications) while {petsName13} is with us for their procedure?*

YesNo
Preventative Care Options
Do you need any refills of heartworm and/or flea and tick preventatives (Heartgard Plus, Nexgard, Nexgard Plus)? If so, which product(s) and how many doses would you like?*

NoYes (please note which product(s) and how many doses you would like)
Do you need any refills of heartworm and flea preventatives (Revolution Plus)? If so, which product(s) and how many doses would you like?*

NoYes (please note which product(s) and how many doses you would like)
Do you need any refills of flea/tick preventatives (Nexgard or Frontline Gold)? If so, which product and how many doses would you like?*

NoYes (please write which product and how many doses you would like)
Do you need refills of medications? If so, which medications and how much would you like?*

NoYes (please note which medication and how many doses you would like)
If {petsName13} is due for vaccinations, and if the doctor feels it is safe to vaccinate your pet following the surgical procedure, would you like us to update vaccines today?*

My pet is not due for any vaccines.I do not want to update vaccines at this time, even if there are any vaccines that are due.Yes, please update any vaccines that are due. I understand that there will be an annual exam fee charged if my pet is due for their annual exam.I would like to discuss this with my pet's care team at the time of their procedure.
Is there anything else you would like us to know about {petsName13} prior to their anesthetic procedure? (i.e. your pet has had an adverse anesthetic event in the past, your pet hates being confined in a kennel, etc)*

NoYes (please explain)
Do you have any other questions prior to {petsName13}'s procedure?*

NoYes (please explain)
Consent for CPR or DNR
For every patient in our care, we need to know, in advance, what your wishes are if your pet stops breathing and/or their heart stops beating. We will make every attempt to contact you right away should your pet require resuscitative efforts. Additional expenses are incurred with the attempt to resuscitate the patient. Please review and select one option below.

Cardiopulmonary Resuscitation (CPR): All resuscitative efforts are to be attempted to restore normal heart function and breathing as deemed necessary by the doctor until I can be reached. Should my pet require cardiopulmonary resuscitation (CPR), I request that the doctor(s) may pursue such medical care indicated above. I understand that this is a cost in ADDITION to any estimate and agree to pay this fee. The cost of full CPR is typically an additional $300 - $500 or more. Patients who require CPR typically need at least 24 to 48 hours of intensive care and monitoring at a speciality facility following resuscitation.

Do Not Attempt Resuscitation (DNR): Aside from reversing any reversable sedatives or anesthetic drugs that have been administered, no cardiopulmonary resuscitation (CPR) efforts are to be attempted.
I have read, understood, and agree to the above terms, and select the following for my pet:*

Cardiopulmonary Resuscitation (CPR)Do Not Attempt Resuscitation (DNR)I don't understand the above terms and need to discuss with a staff member before I decide my pet's CPR or DNR status.
Signature of Consent
I am aware that (unless specifically instructed otherwise) my pet cannot receive food after 10 pm the evening prior to their procedure, and that if food is consumed the morning of the procedure, the procedure may need to be postponed or cancelled. I am the owner of the above named animal, or I am responsible for the above named animal, and I have authority to administer this consent. I hereby authorize the performance of the above listed procedure(s) and I am comfortable with my level of understanding of the procedure(s) to be performed. I understand that each patient having a procedure performed under general anesthesia will receive an IV catheter and IV fluids, and most will be monitored with an ECG, pulse oximeter, blood pressure, and capnograph. I understand there exist risks and complications to the above listed procedure(s). If, during the course of the operation/procedure unanticipated conditions are revealed that require an extension of the original procedure, I extend the authority granted under this paragraph to remedy conditions that are not known to the doctor(s) at the time the operation/procedure is commenced, but are necessary and desirable in their professional judgment. I consent to the administration of such anesthetics, drugs, I.V. fluids, and/or other medications, as may be considered necessary or advisable by the veterinarian(s) responsible for this service. I further acknowledge that no guarantee or promises have been made to me related to the outcome of the above mentioned procedure(s). I acknowledge full responsibility for the payment of fees related to these services, and I understand that all fees are to be paid at the time services are performed. I understand that my pet's procedure may need to be rescheduled due to circumstances such as another pet having a more urgent need for surgery, weather conditions that make it unsafe for clients and staff to travel to the clinic, or other situations outside of the control of St Francis Animal Hospital. I certify that I have read and understand the contents of the above mentioned authorization and consent.*
Signature*

Clear
Procedure and risk information adapted from Client Consent Forms, From Cohn and Côté: Clinical Veterinary Advisor, 4th edition. Copyright © 2020 by Elsevier Inc. All rights reserved.
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Anesthetic Procedure Consent Form

Patient Information

Procedure Information

Pre-Surgical Preparation

Spay/Neuter Procedure

Mass Removal

Cystotomy

Enucleation (eye removal)

Amputation (limb, toe, tail)

Gastropexy

Dental Cleaning, With or Without Extractions

Oral Mass Removal

Orthopedic Surgery (fracture repair, cruciate ligament repair)

Preventative Care Options

Consent for CPR or DNR

Signature of Consent