denveranimalhospital.org - Surgery Consent Form

Client’s Name:

Patient’s Name:

Phone number(s) to be reached at today:

Please enter a valid phone number.Format: (000) 000-0000.

Secondary Number to be reached at today:

Please enter a valid phone number.Format: (000) 000-0000.

Procedure:

Add On Procedure(s):

YesNo

If yes, what is the date of the last day of the cycle?

Last time meal/treat given:

Last time water given:

List all Medications given today (including time given):

List all Medications given regularly, but not given today (include frequency):

Does your pet have a history of vaccine or medication interactions (if yes, please list)?

YesNo

If yes, please describe:

YesNo

If yes, please describe reaction:

List any belongings left with your pet:

DAH is not responsible for any lost items

Bloodwork:

Yes

Initial

YesDecline

Initial

YesDeclineCall First

Initial

YesDeclineAlready Chipped

Initial

Authorizations:
initial   While I accept that all procedures will be performed to the best of the abilities of the staff at Denver Animal Hospital, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. I agree to assume financial responsibility set forth in the treatment plan, and provide payment via cash, credit card, Care Credit, or ScratchPay at the time my pet is discharged from the clinic.

initial   I understand that the anesthetic, surgical or therapeutic procedures may involve the risk of complications, injury, or even death, from both known and unknown causes. No warranty or guarantee has either been expressed or implied as to the result or cure. **

Should unexpected life-saving emergency care be required and the clinic staff is unable to reach me: (initial one please):
initial   Denver Animal Hospital has my permission to provide such treatment, to include CPR and administration of emergency drugs, and I agree to pay for such services (The cost associated with this is typically between $300-$500 over the initial surgery estimate; CPR procedures will be performed until the doctor deems that life-saving efforts cannot be achieved).
initial   Denver Animal Hospital does NOT have my permission to pursue CPR procedures or any emergency treatments.

I authorize the above surgical procedure(s) for my pet. I authorize any additional diagnostics, treatments, and/or surgical procedures deemed necessary for medical or surgical complications or any unforeseen circumstance. The nature and risks of this procedure have been explained to me and I am encouraged to discuss any concerns with my veterinarian before the procedure is performed. I understand Denver Animal Hospital will do everything possible to reduce any risks. My signature indicates that any concerns or questions have been addressed and I authorize Denver Animal Hospital to proceed. I will not hold Denver Animal Hospital, the veterinarian, or staff liable for any complications that may arise. I have read and fully understand the information provided on this form.

Printed Name of Owner or Pet Guardian:

Signature of Owner or Pet Guardian:

Date:

Date

**About Our Anesthesia:

Denver Animal Hospital (DAH) chooses specific anesthesia protocols for each patient after an exam and bloodwork (performed prior to any procedure). We place intravenous (IV) catheters and run IV fluids on all major procedures done at DAH. Sevoflurane, the anesthetic gas used to maintain your pet under anesthesia, is the latest and safest in veterinary medicine. Most pets make a smooth and rapid recovery. While under anesthesia, your pet is monitored with state-of-the-art equipment by a dedicated veterinary technician and veterinarian. Vital signs monitored include: heart rate and rhythm, blood pressure, oxygen, CO2 percentage, respirations, and temperature.

Your pet’s comfort is important to us; warming tables, blankets, and other techniques are utilized during each procedure and recovery. Pain management is a top priority and we provide appropriate pain medications specific to each patient’s needs before, during, and after each procedure. If you have more questions about the comfort of your pet or pain management techniques, please feel free to ask.

DAH would like to remind you that anesthetic and surgical procedures are not without risk. We encourage you to discuss any and all concerns you may have with your veterinarian before your pet’s procedure is performed.

Surgery Consent Form

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