Anesthesia/Procedure Consent Form

ANESTHESIA/PROCEDURE CONSENT FORM
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Phone number where you can be reached during the procedure*

Area CodePhone Number
Email*
example@example.com

Patient Information
Pet's Name*
Species*
Date of Birth or Estimated Age*
Sex*
Breed*
Color
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 between 7:30 and 8:00am. Please allow 15-20 minutes to be checked in.
PROCEDURE BEING PERFORMED*

Spay or castrationMass Removal(s)Dentistry (with extractions if necessary)Laceration/Wound RepairAural (ear) Hematoma RepairLance/drain abscessDeclaw (front paws only)Orthopedic surgery (fracture repair, cruciate ligament)Cystotomy (bladder surgery)Enucleation (eye removal)Amputation (limb, toe or tail)Gastropexy
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.
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.
Dental Cleaning (scaling and polishing), 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. 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, if possible or necessary, 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, if possible or necessary, 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.
What is declawing in Cats?


Cat declawing is the surgical removal of the small bone on the end of each toe. In most cases, only the front paws of a cat are declawed. As a surgical procedure, it requires general anesthesia and sufficient pain management throughout the recovery procedure. It generally takes a few days to a few weeks for healing to be completed, after which time the cat can walk, climb, knead and scratch comfortably. Anecdotally, adult cats and those that are heavier may take longer to heal and adapt. Your cat will be hospitalized for one night after the surgery, and pain management medications may be dispensed for the first few days that your cat returns home. In many cases, a special, dust-free kitty litter may be recommended to prevent contamination of the surgery sites until the paws are entirely healed.
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. A sample of urine or 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 there is 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 typically those associated with 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.
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.
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.
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 retained deciduous teeth are identified, would you like us to remove them during this anesthetic procedure? Cost is ~$12/tooth.*

Yes, proceed with any recommended extractions.No, do not perform any extractions.I would like a call to discuss the next steps if it is found my pet has retained deciduous teeth.
If my pet requires dental extractions:*

I authorize all necessary extractionsI prefer to be called before any extractions are performed. If I cannot be reached, I authorize you to proceed with all necessary dental procedures.If I cannot be contacted by phone, I do not authorize any extractions to be performed. *Please be aware that if you decline any needed procedures at this time, your pet would need a second anesthesia at another time in order for those procedures to be performed.*
Do you want histopathology (biopsy) performed on the removed mass(es)? (additional charges apply)*

YesNo
All uses of anesthesia do involve risks. We recommend a blood profile to ensure that your pet is in a low risk category. Results of these tests will help determine your pet’s readiness for surgery. Depending on the results, we may adjust the dose or type of anesthetic used, advise fluid therapy, or delay/cancel anesthesia/surgery.*

Pre-anesthetic panel $75.00 -This profile includes chemistries that screen for kidney disease, liver disease, and diabetes. The liver and kidneys are the major organs responsible for metabolizing anesthetic drugs.Complete Chemistry panel with electrolytes $112 -This profile checks 21 analytes that provide in-depth screening for kidney disease, liver disease, diabetes, gastrointestinal disease, pancreatic disease, dehydration, and an indicator of certain types of tumors. Electrolyte abnormalities can be symptomatic of systemic illness.Complete Chemistry panel with electrolytes and CBC $165 - This profile includes the Complete Chemistry as described above and a complete blood count (CBC). A CBC assesses anemia, infection, and possible clotting problems. Low platelets can indicate a serious problem related to bleeding during or after surgery.I DECLINE ALL BLOODWORK.
To protect the surgical site, your pet may need an E-collar (cone). Which option would you prefer we send home with your pet? (not necessary for dentistry)*

E-collar ($10-$20)I already have an e-collar for my pet.Topical taste deterrent $20 (please note this does not work for all patients)
Would you like medication sent home to help keep your pet less active after surgery?*

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 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 is under anesthesia? Cost for this procedure is $55.*

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
If your pet is due for vaccinations, and if the doctor feels it is safe to vaccinate your pet following the procedure, would you like us to update vaccines today? (Please note that the core vaccines, distemper and rabies, are required to be current in order to be in the hospital)*

My pet is not due for any vaccines.I do not want to update vaccines at this time, even if any vaccines are due.Yes, please update any vaccines that are due.
If your pets has fleas, he/she will be treated at the discretion of the doctor unless a product preference has been selected.*

Vectra 3D (dogs) 1 month topicalCredelio (dogs) 1 month oralBravecto (dogs) 1 month oralBravecto (dogs) 3 month topicalBravecto (dogs) 3 month oralCatego (cats) 1 month topicalRevolution (cats) 1 month topicalBravecto (cats) 3 month topical
Signature of Consent
Please read carefully.*

I am aware that (unless specifically instructed otherwise) my pet cannot receive food after 10pm the evening prior to the procedure, and that if food is consumed the morning of the procedure, the procedure may need to be postponed or canceled.I am the owner of the above named animal, or I am responsible for the above named animal, and I have the 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 consent to the administration of such anesthetics, drugs, IV fluids, and/or other medications, as may be considered necessary or advisable by the veterinarian(s) responsible for this procedure.I understand there exist risks and potential complications to the above listed procedure(s). If, during the course of the 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 procedure is commenced, but are necessary and desirable in their professional judgement.I further acknowledge that no guarantees 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 the services are performed.I certify that I have read and understand the contents of the above mentioned authorization and consent.
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ANESTHESIA/PROCEDURE CONSENT FORM

Patient Information

PROCEDURE INFORMATION

PRE-SURGICAL PREPARATION

Signature of Consent