Jacksonville Veterinary Hospital's Surgical Consent Form

Owner's Name*

First NameLast Name

It is imperative that you or a responsible person authorized to make medical and financial decisions on your pet's behalf is available at the emergency contact numbers below:

BEST CONTACT PHONE NUMBER:*

This number should reach the primary person authorized to make medical and financial decisions for the pet.

Secondary Phone Number*

This person should be available in case of emergency and be authorized to make medical and financial decisions for thet pet.

Animal's Name*

Species*

CanineFelineOther/Small Mammal

If "other" species, please list speciesname of species here

Breed*

Fill in the breed of animal. Example: Golden Retriever

Color/Description*

Fill in the color/any special markings on your pet

Sex*

MaleFemaleMale NeuteredFemale Spayed

*All surgical and sedated procedures must be discussed with the Veterinarian and/or receptionist IN ADVANCE of scheduling. If you need to adjust or add something to your pet's procedure please call 410-666-1390 BEFORE the date of the appointment. PLEASE SELECT THE SURGICAL PROCEDURE TO BE PERFORMED:*

SpayNeuterMass Removal(s) with NO DENTALMass Removal(s) with DENTALDental cleaning and polishing only (may include extractions)Spay with Dental (dental must be recommendedby the vet)Neuter with Dental (dental must be recommended by the vet)OTHER/DESCRIBE BELOW (must be discussed with Veterinarian)

If OTHER or you have additional notes needed, please describe procedure in detail: name/description of procedure(s)

For Mass Removal(s), we will ask you on the morning of surgery to identify the exact locations of each mass to be removed. You must clearly mark each mass that you wish to be removed at the time of drop off. We cannot guarantee we are meeting your expectations to remove all masses if they are not marked that morning and will not be held liable if the mass was not discussed/marked. IN SIGNING BELOW YOU ARE ACKNOWLEDGING YOU HAVE READ AND UNDERSTAND/AGREE TO THE ABOVE STATEMENT.

We have prepared for your pet's surgical procedure well in advance, and according to this form. YOU MAY NOT ADD ON ADDITIONAL MASSES OR SERVICES AFTER THIS FORM HAS BEEN SUBMITTED. (You could, however, call to discuss options). IN SIGNING BELOW YOU ARE ACKNOWLEDGING THAT YOU CANNOT ADD ON ADDITIONAL MASSES OR SERVICES ON THE DAY OF THE PROCEDURE.

If you would like to add on a Dental (cleaning/polishing), please make sure this is arranged in advance with our front desk for scheduling purposes by calling 410-666-1390. Then proceed below.

Yes, please add a dental cleaning and polishing while my pet is under anesthesia.No, I decline to add on a dental cleaning/polishing while my pet is having the procedure listed above.

Would you like an estimate? If so, please select yes and CALL OUR OFFICE AT LEAST 5 BUSINESS DAYS BEFORE THE DATE OF THE PROCEDURE.*

YES, I will call and request an estimate giving at least 5 business days notice.No thank you, I decline to receive an estimate and accept all charges accrued.I have already received/approved a recent estimate and do not need another. *ESTIMATES ARE VALID FOR ONE MONTH FROM THE DATE OF THE PROCEDURE.

FOR DENTALS:

The condition of your pet's teeth will be evaluated at the time of the procedure while under sedation. Teeth that pose a risk to your pet's health may have to be extracted and are charged accordingly based on tooth type and extraction difficulty. This may not be included in your estimate. Our veterinarians recommend that all extractions be performed during this dental procedure to reduce future cost to the owner, decrease the risk of infection, and reduce the risks associated with additional anesthesia.

Please select ONE of the following options for your pet's dental:*

Please perform extractions as the Doctor deems necessary (for an additional cost). You do not need to call me first.Please call me before extractions are performed. If I am not available you may perform extractions as necessary.Please call me before performing extractions. If I am not available, DO NOT perform extractions. I understand the increased risk of infection to my pet, and that I may have to return for additional anesthesia, extractions, and cost at a future date.

FOR MASS REMOVALS: Describe EXACTLY where each mass is located that you would like the veterinarian to remove. We will also ask you the morning of surgery.*

be as descriptive as possible

Additional Mass

Would you like the mass(es) sent to our lab for a biopsy? (Additional fee of $338 per mass applies). This gives us more information about the types of cells in the mass, surgical margins, likelihood of metastasis, etc. In some cases, results could be inconclusive.*

Yes please send the mass(es) to the lab for a biopsy for an additional fee. **If more than one mass is removed, please indicate which masses you wish to be biopsied.**No, I decline to have the sample sent to the lab for a biopsy. I understand I will not receive information about the cells that were found in the mass.

Does your pet have a history of medical conditions, cardiac problems, or seizures?*

YesNo

Please describe your pet's medical problem.*

Is your pet on any medications?*

YesNo

List all medications that you currently give, complete with instructions and last dose given

List all medications you currently give, complete with instructions and frequency.

While the anesthetics that our Veterinarians use are considered safe for your pet, we strongly recommend evaluating your pet's internal health by checking a blood sample before surgery. These values allow the Veterinarian to determine how your pet's body will process anesthesia and affect which type of medications the vet is able to give your pet for the procedure itself and for pain management after. We strongly encourage bloodwork before the procedure. As with any surgery, there can be potential for complications to arise both during and after a patient has been under anesthesia. Pre anesthetic bloodwork allows us to evaluate any hidden/ internal problems your pet may have before he/she is sedated.*

YES, I would like my pet's bloodwork evaluated before he/she is sedated. I understand the blood panel and the additional cost thereof, which varies based on age.NO, I do not wish to have my pet's bloodwork evaluated before he/she is sedated. I understand, in refusing this service, that I assume all responsibility for any problems that may result from waiving the preliminary blood screening today.My pet has already completed the required bloodwork within the past 90 days and has been cleared for surgery by the veterinarian. If you are unsure please call 410-666-1390.

Please select any additional services you authorize and would like us to perform today.

Heartworm, Lyme, Ehrlichia, and Anaplasmosis test (4DX)Fecal analysis (for intestinal parasite screening)DAPP vaccine (canine distemper/adenovirus/parvovirus/parainfluenza) *Exam requiredRabies vaccine *Exam requiredLeptospirosis vaccineLyme vaccineBivalent Influenza vaccineBordetella vaccineMICROCHIP

Please select any additional services you authorize and would like us to perform today.

Fecal analysis (for intestinal parasite screening)Rabies vaccine *Exam requiredFVRCP (Feline distemper/rhinotracheitis/calici/paneukopenia virus vaccine) *Exam requiredFeline Leukemia vaccineFeline Leukemia/FIV blood testMICROCHIP

Your pet's nails will be automatically trimmed while under sedation complimentary/free of charge unless you indicate you do not want them trimmed.*

YES trim my pet's nails while under sedation.NO do not trim my pet's nails while under sedation.

Laser therapy uses specific wavelengths of light to reduce inflammation, reduce pain, and speed up the healing process. Many of our patients benefit from laser therapy regularly. Certain patients may not be good candidates for laser therapy, however, if the Veterinarian recommends a post surgical laser treatment during your pet's procedure, do you approve this service?*

Yes, please administer laser therapy to my pet during his/her procedure ($27).No, I decline laser therapy for my pet.

After your pet's procedure, we may recommend an elizabethan collar or a medical pet shirt if the doctor deems necessary. If fitted/worn properly, the item will allow the incision to be protected after surgery. May we have your permission to pre-fit the recommended item to your pet?

Yes, you have my permission to size the appropriate post op protection item to my pet and send it home.No, I have one at home. I understand the item needs to be fitted according to the pet's current size, and that it must prohibit the pet from reaching this particular surgical site. The Doctor recommends my pet to wear one at all times during recovery.No, I understand the Vet has recommended this item for my pet's post op recovery in order to keep the surgical site protected, and that without it I acknowledge there is risk of the incision being reopened or not healing properly. I decline this item at this time.

I, the owner or responsible party of the above named animal, am admitting my pet to Jacksonville Veterinary Hospital and its Doctors for care and hereby:

Allow anesthetics, sedatives, pain management, and surgical/therapeutic procedures as veterinarians advise.
Acknowledge that in the event I am unavailable at the emergency contact numbers listed below and my pet has a medical emergency while here, that the veterinarian may treat by any means necessary to provide supportive care and alleviate suffering until contact is made. If my pet needs 24 hour supervision which is not provided at this hospital, I authorize transport of my pet to a local emergency hospital.
Hold Jacksonville Veterinary Hospital and it's doctors harmless from and against any and all liability arising out of procedures listed below and any therapeutic/emergency treatments.
I authorize the following surgery/procedure and agree to take financial responsilbility for the services listed on this form and any associated services.

PRINTED NAME OF LEGAL OWNER OR RESPONSIBLE PERSON FOR THIS ANIMAL*

Signature*

Today's Date*