Surgical & Sedation Admission Form

Date of Procedure

Pet's Name*

Pet Owner's Last Name*

Phone Number where I can be reached on the day of the procedure:*

Please enter a valid phone number.

What procedure is your pet be coming in for?*

Last heat cycle*

Dental Cleaning and/or Extractions:

A dental exam under anesthesia includes x-rays, checking the teeth for mobility, probing the gums for pockets, and checking for broken or diseased teeth. Based on the results of my pet's dental exam, the attending veterinarian will decide if any teeth must be extracted to improve the overall health of my pet.

I understand that the extent of the dental disease cannot be assessed until the patient is anesthetized and a thorough dental exam/cleaning is performed. I understand that diseased teeth can lead to heart, kidney, liver disease, and/or abscesses if left untreated.

I authorize the extraction of any teeth at the doctor's discretion and am aware that this is for the benefit of my pet's health and quality of life.*

What area are we obtaining radiographs on? (Example: right front shoulder)*

How many masses/growths are to be removed?*

Describe where the mass or growth is located*

Would you like to send the tissue to the lab for a biopsy?*

YES ($525 for one site; complex biopsy is $883. Please refer to your estimate.)NO, I understand that the doctor will not be able to identify if the tissue is benign or malignant without microscopic examination

Surgical Limb- specify front or back and left or right*

Does your pet have any known, chronic conditions?*

YesNo

Please list all conditions:*

Is your pet currently taking any medications?*

YesNo

Please list all medications including strength, how often, and when it was last given. *

Does your pet have any known allergies?*

Food allergiesEnvironmental allergiesAllergies to medication(s)None

What medication is your pet allergic to and what is the reaction?*

Has your pet ever had anesthesia or been sedated?*

YesNo

Were there any issues or complications?*

YesNo

Please describe:*

Is your pet taking monthly flea/tick and heartworm prevention?*

YesNo

Please list preventatives*

When was the last dose given?*

All dogs must have a NEGATIVE heartworm test prior to undergoing anesthesia. If your dog's heartworm test is not current, the test will be performed prior to anesthesia.*

I understand that if my dog's HW test is not current, the team at Maywood Vet will perform the test prior to administering any anesthesia. ($96)

Initials*

Has your pet experienced any coughing, sneezing, vomiting, or diarrhea within the last 48 hours?*

YesNo

Please describe any symptoms your pet has had including date of onset. *

Please select any additional services you would like performed while your pet is under anesthesia.

Insert Home Again Microchip ($63.60)Extract Retained Baby Teeth ($48.80 per tooth)Express Anal Glands ($49)Update past due vaccinationsDoctor exam of area of concern

Please let us know what additional areas of concern you would like the doctor to check. *

If an elizabethan collar is recommended for the post-operative recovery period, please let us know if you would like to receive one from us.*

Yes, please send my pet home with an elizabethan collar ($7-$18 depeding on size)No, I am opting not to use a collar against medical adviceNo, I have a collar at home or will purchase one from another source

Medications such as antibiotics and/or pain medication may be prescibed. There is not always an option but, if the option can be tailored, which form of medication would you prefer? IF YOU CHOOSE INJECTABLE, PLEASE ALSO CHOOSE A 2ND OPTION IN THE EVENT INJECTABLE IS NOT POSSIBLE.*

Injectable medicine given by Maywood Vet so I do not have to medicate at home (this option is more costly than pills/liquid)Pills to be given at homeLiquid to be given at homeI cannot medicate my pet

Anesthetic/Surgical Risks:

Despite the best efforts of the doctors and supporting staff at Maywood Veterinary Clinic, no anesthetic procedure is without risk, even in apparently healthy animals. These risks may include but are not limited to hemorrhage, hypothermia, decreased heart rate or respiratory rate, post-operative complications (i.e. surgical site breakdown, implant failure/rejection, secondary infections), and even death.

I understand these risks and that the doctors and supporting staff of Maywood Veterinary Clinic will do their best to minimize said risks.

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions.

Initials*

Life Saving Efforts: I understand that despite the best efforts of the doctors and supporting staff, anesthesia and surgical procedures involve the risk of complications, injury, or death. No warranty or guarantee exists regarding the results or cure. Please tell us how you would like us to proceed in the event of an emergency:*

Please perform CPR and administer medications as needed. CPR means that you authorize establishing an airway for your pet, breathing for your pet, external chest compressions, and the adminsitration of drugs and fluids to try and establish circulations and respiration. I understand that even if CPR is successful in restoring my pet's life, it may not allow for my pet to regain his/her normal mental and/or physical health. If CPR is successful, patients may require 24 hours or more of ongoing hospitalization and care and a 24 hour care facility may be recommended. I agree to be held responsible for the costs associated with any resuscitation attempt that is made on my pet.Do Not Resuscitate (DNR) I do not authorize resusciative efforts if my pet should suffer cardiopulmonary arrest (heart and lungs stop functioning). I understand that if my pet suffers from cardiac arrest, respiratory arrest, collapse or unconsciousness, and CPR is not performed, my pet will pass away.

Initials*

I certify that I own the above described animal and I do hereby consent and authorize the Maywood Veterinary Clinic and its Staff to hospitalize this animal and to administer medications, tests, surgical procedures, anesthetics and/or treatments that the doctors deem necessary for the health and well-being of the animal while it is under their care and supervision. I do hereby release the Maywood Veterinary Clinic and its Staff of any responsibility and/or liability in the absence of gross negligence in the event that this animal should injure itself, refuse food, become ill or die while in clinic. I further realize that I am responsible for payment for the above procedures and treatments. In the case of non-payment, I realize that I am responsible for a collection agency fee of $25 and/or attorney fees necessary to collect the full amount due to The Maywood Veterinary Clinic. I further agree that in case of non-payment a finance charge of 1.5% per month (18% APR) will be charged.

If I neglect to pick up the animal within FIVE (5) days of written notice you may assume that the pet is abandoned. Abandonment does not release me of my obligation for the bill.

I have read and understand this authorization and consent. I take full responsibility for payment at the time of service. *

Today's Date

Date