SURGERY CONSENT FORM

SURGERY CONSENT FORM
Email
example@example.com
DATE

MonthDayYear
Date
OWNER'S NAME
ANIMAL'S NAME
SPECIES
SEX
AGE
COLOR
PRE-ANESTHESIA SCREENING:

Our greatest concern is the safety of your pet. Our doctors will give your pet a thorough physical examination before the anesthetic procedure. However, there may be hidden problems that could cause an anesthetic complication if undetected. We, therefore, require pre-anesthesia blood testing for all pets undergoing surgery. Blood tests should have already been performed and the results discussed with you. If we detect a significant problem on the exam the morning of surgery, we will contact you prior to starting the procedure.

INTRAVENOUS CATHETER AND FLUIDS:

Giving fluids ensures good blood flow to the body’s tissues during an anesthetic procedure and helps with the elimination of anesthetic drugs post-operatively, often resulting in a quicker recovery. An intravenous catheter also gives immediate access to the bloodstream should emergency medications be needed. All pets undergoing a surgical procedure, other than feline castration, will have an intravenous catheter placed prior to surgery and will receive intravenous fluids during the surgical procedure.

POST-OPERATIVE CARE:

Depending on the procedure your pet is having, the following items may be sent home with you:
- Pain medication: If a painful procedure is performed, your pet will receive pain medication at the time of surgery and/or oral medications sent home with you
- Elizabethan (cone) collar: Any procedure that involves an incision that could be disturbed by your pet will be fit for an E-collar. If you have one at home, please let us know and bring it with you to your pet’s discharge.
- Antibiotics, tranquilizers, and other medications may be dispensed on a case-by-case basis, depending on your pet’s procedure
I am the owner of the above-named animal or am responsible for it.
I have the authority to execute this consent.
I authorize the performance of the following procedures:
I authorize the use of such anesthetics as you deem advisable and performance of such surgical or therapeutic procedures as you determine to be indicated. The nature and risks associated with the procedure(s) have been explained to me and no guarantee has been made as to the results. I agree to indemnify and hold Golden Valley and Greenbrier Animal Hospitals harmless from and against any and all liability arising out of any of the procedures referred to above. I grant Golden Valley and Greenbrier Animal Hospitals permission to post my pet’s picture, story, and medical information on social media. NOTICE - THIS ANIMAL HOSPITAL DISPOSES OF ABANDONED ANIMALS IN ACCORDANCE WITH MINNESOTA STATUTES 346.37, SUBD. 1. BY SIGNING THIS DOCUMENT YOU ACKNOWLEDGE HAVING RECEIVED A COPY THEREOF ON THE DATE INDICATED.
SIGNATURE OF OWNER OR RESPONSIBLE PERSON

Clear
PHONE NUMBER WHERE YOU CAN BE REACHED DURING THE PROCEDURE
I DO NOT want my pet's picture, story or medical information on social media
Please check additional services you would like performed while your pet is here. There is an additional charge associated with these services. Please ask our staff for an estimate.

Express anal glands/bathe areaImplant microchip for identificationClean earsTrim nailsFecal (to check for intestinal parasites)
Please indicate additional treatments desired
Please list any medications your pet currently takes and whether he/she got them this morning:
Should be Empty: