Surgery Consent Form

Surgery Consent Form

Please fill out this form in entirety to ensure we can provide your pet with profound personalized care. If you need to cancel/reschedule your pet's procedure, please provide a 48 hour notice to allow us to provide care to another patient in need. A cancellation fee of $100/hour reserved will be billed for surgery appointments without a 48 hour cancellation/reschedule notice.
Your Name*

First NameLast Name
It is imperitive that we be able to reach you in a timely manner while your pet is admitted for surgery today.
Best Contact Number*

Area CodePhone Number
Is there anyone else we can call regarding your pet while they are here today?*

YesNo
Alternative Contact Name

First NameLast Name
Alternative Contact Phone

Area CodePhone Number
Patient's Name*
Pet's Name
I authorize Urban Veterinary Associates to perform the following procedure(s) on the patient listed above:*

SpayNeuterDentalMass RemovalOrthopedic Surgery (CCL Repair, Fracture Repair, etc)Other
For spay patients, please list the date of your pet's last day of their heat cyle. Type N/A for non-spay patients or if your pet has not had their 1st heat cycle. *
For the patient's safety, our doctors recommend spaying your pet at least 8 weeks after the last day of their heat cycle.

If the patient's last day of their heat was not 8 weeks ago, there may be additional costs for their procedure or we may have you reschedule. There is increased risk for intra-operative and post-operative hemorrhage for pets spayed in close proximity to their heat cycles.

Please reach out at 630-541-8088 if you have any questions or concerns.
For orthopedic patients, please confirm which leg(s) need surgically repaired. (Select all that apply/Select NA for non-ortho procedure)*

Front Left LegFront Right LegBack Left LegBack Right LegNA
Appointment Reminder: Patient should be fasted after midnight before the procedure. Please admit your pet at 8:45am. Any admittance after 9am may be rescheduled and a cancellation fee will be incurred. If you need to cancel or reschedule, please provide a 48 hour notice. Please initial to acknowledge the statement. *
Initials
Has your pet been vomiting or having diarrhea?*

YesNoUnsure
Does your pet have any allergies?*

YesNoUnsure
If yes, please describe/provide more information
Has your pet ever had any adverse reaction to medication?*

YesNoUnsure
If yes, please describe/provide more information
Please list any medications, supplements, topical treatments your pet has received in the past 72 hours and when they were last given:*
When Was Your Pet's Last Dose of Flea/Tick Preventative?*
Date Given (Please type N/A if not on a preventative)
What Kind of Flea/Tick Preventative Do You Use?*
Name of medication - put unknown if not sure
Is There Anything Else We Should Know About Your Pet?
If yes, please tell us more. If no, please note N/A
Authorizations
I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize treatment of my pet to be performed by Urban Veterinary Associates. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian.*
Initial
I have been advised as to the nature of this procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any sedation or anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. This risk includes serious bodily injury or death. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. I accept responsibility for any result in additional charges.*
Initial
I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital).*
Initial
Dental Extraction Consent Form

I understand that some of the dental disease and pathology for my pet may not be revealed until the complete oral examination and radiographs have been completed. If additional treatment is necessary, I understand that any possible extraction can range from $20 - $300/extraction.
*FOR DENTAL PROCEDURES ONLY* In the event that there are additional teeth that require treatment/oral surgery that exceed the treatment plan provided at admittance, I elect for the following*

Proceed with all necessary treatments that the veterinarian feels are necessary. I assume financial responsibility for the additional associated costs.Please call me at the number listed above prior to any additional procedures deemed necessary prior to performance. I understand that if I cannot be contacted, these procedures will NOT be performed and may require an additional procedure for them to be addressed.Do not perform any additional procedures beyond the initial treatment plan.Not Applicable
CPR CONSENT

In the event of an unforeseen emergency, Urban Veterinary Associates will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached.

Should your pet require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency medications, or other heroic interventions, would you request that the doctor at Urban Veterinary Associates conduct such medical care?

If you request such emergency procedures, you agree to be held responsible for veterinary services provided to your pet while staff members pursue treatment and try to reach me for further directions. Regardless of your pet’s recovery or survival, you agree to pay CPR fees in addition to other fees already identified by the practice and agreed upon by me.
Please accept or decline CPR treatment*

Please proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred.Please do not proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred.
I accept that if the hospital staff is unable to reach me within 20 minutes after the initial CPR procedures, and after exercising reasonable medical judgement, determine that there is no hope for success, the staff will cease further CPR procedures. I understand that despite the best effort of the doctor and staff at this facility, even the most successful CPR that my restore my pet’s life may not allow for my pet to regain his/her normal mental and physical heath and, thus, may leave him/her as an invalid. *

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Surgery Consent Form

Authorizations