Surgical, Sedation, and/or Hospitalization Consent Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

It is very important that we have a current phone number in order to reach you at ANYTIME during such treatments, procedures, or surgeries. Please leave the phone number that we can reach you at ANYTIME today.

Phone Number

Please enter a valid phone number.

We at Belmont Veterinary Center understand that it may be difficult to personally bring your pet to their appointment. Therefore, we would like the names of any spouse, caregiver, child (over 18) or friend that may initiate treatment on your behalf. Leave Blank if not applicable.
First Name Last Name Relationship:

Pet Name, Breed, Age and Sex of Pet

Surgery or Procedure to be Performed:

If Other Please Explain:

There are increased risk with spaying a female pet whom have been in heat with in the past 8 weeks. It roughly takes 6-8 weeks for the blood vessels to return to normal (smaller in size). If you choose to proceed we will take as many precautions as needed but this still may lead to an increased cost. Post operative complications including hemorrhage and delayed healing is possible.

Would you prefer a phone call or Text message when your pet is ready to be picked up

Phone CallText Message

Any medication and/or supplements in the last three days?

YesNO

If yes please list:

Any of the Following:

Is your pet allergic to anything, please list if any?

Vaccination History: Has your pet received the following vaccinations? If "yes" and not provided by the Belmont Veterinary Center you will need to provide record of any prior vaccinations, along with any prior medical history before the day of the procedure. State Law mandates that ALL dogs and cats be vaccinated for Rabies Virus. We at the Belmont Veterinary Center also require the following vaccinations for dogs, DA2ppv, Bordetella, Influenza, and for cats PRCC. Pets must have been vaccinated by a veterinarian for insurance and liability reasons. All pets undergoing surgery or staying in our hospital must have proof of current vaccination status. If your dog or cat is not current on vaccinations, they will be given post-operatively. A booster vaccination in 2-4 weeks may be required.

Distemper (dogs and cats)Rabies (dogs and cats)CIV k-9 influenza (dogs only)Bordetella (dogs only)

Other Services to Perform Today

We recommend administering a mild sedative the night before and the morning of surgery (or other procedures) prior to drop off. This helps relieve any anxiety before their procedure and helps ensure a calm recovery from anesthesia. We will dispense this before your pet's scheduled procedure for pick up. Would you like us to dispense this for your pet.

YesNo

Your pet can be fitted and sent home with an e-collar after the procedure if you are concerned your pet will disrupt the site. Would you like your pet to be fitted for one?

YesNo

Pets heal best when they are kept calm after surgery. If you are worried about your pets energy level we can send home medication to help keep them calm. Would you like some medication sent home?

YesNo

Pre-Anesthesia Blood Work

We require all dogs over the age of 1 to have a heartworm check with in the last year.

We require all feline patients to be tested for Feline Immunodeficiency Virus and Feline Leukemia. If your cat is an indoor only cat and has no access to other cats outside your home, only 1 test is needed as long as they remain indoors. If your goes outside in any capacity, we require a feline combo test annually.

Anesthesia is required for most surgical procedures. We require blood work on most cases to assess organ function prior to anesthesia. There are different panels for different ages of pets. Should an abnormality exist we will contact you before proceeding.

Pets under 2 years of age optional blood screen $161.50

Pets over 2 years of age to 4 years of age. $222.50 (includes blood work, respiratory, pulse oximeter, heart rate monitors and other monitoring)

Pets over the age of 5 years $408.50 (includes blood work, respiratory, pulse oximeter, heart rate monitors, other monitoring, IV catheter and fluids and a digital view of the chest.)

Is your dog on any heartworm prevention? If so what brand.

Anesthetic Monitoring
Your pet will have the latest monitoring protocols while under anesthesia. Our patients will have their breathing, heart rate (EKG) blood oxygenation (pulse Ox), blood pressure, respiration and temperature all continually monitored and evaluated by our trained assistants during surgery.
I have read and understand. Signature

Pain/Inflammation
Pain interferes with the healing process therefore we will administer pain medication while your pet is here. You will be given pain medication for your pet to take home after the procedure.
I have read and understand. Signature

Post Op-nausea
Nausea and or vomiting can be a complication from anesthesia and can persit which can interfere with healing. It is our policy to give an anti-emectic. (cerenia)
I have read and understand. Signature

Laser Therapy
We will apply a therapeutic laser light to your pets surgical site for fast healing. this light accelerates natural skin regeneration by working with the skins natural healing response to help wounds and incisions heal more quickly. Therapy can NOT be performed on mass removal site until the mass has been submitted for histopathology and deemed non-cancerous.
I have read and understand. Signature

A histopathology analysis can be performed on abnormal or unknown tissue removed from your pet. This report identifies the tissue, margin, and grading ect. Cost for one submission $208

I accept this chargeI reject this charge and you can trash the massI would like the mass saved for 6 months as I decide

IV Catheter
Your pet will have an IV catheter placed prior to surgery or sedation. (except cat neuters). They will have a shaved area on their forearm. The IV catheter is used to give medication and or IV fluids for the procedure. IV fluids help maintain hydration and blood pressure. An IV catheter also gives access to a vein should need of emergent medications be in need. Not all of our estimates or patients require an IV catheter or IV fluids. If our vets feel an IV catheter and/or IV fluids are needed we will perform these at additional cost to you.
I have read and understand. Signature

Teeth Extractions
If your pet is here for dental teeth cleaning, extractions may be necessary to ensure your pets comfort and dental health. Extractions, medication and any other additional services associated with the dental are NOT included in the cost of a dental cleaning. Payment will be required the day of the dental procedure for these additional fees.
If this does not apply to your pet today please leave blank.
I have read and understand. Signature

Owner Release

If overnight supervision is needed (required) and I the owner elect to pick them up and provide care at home or leave my pet unsupervised at Belmont Veterinary Center, I am aware that Belmont is not staffed 24 hours a day. I accept all risks of adverse effects. I am aware that I have a choice to transfer my pet to the local emergency clinic where overnight veteriarny supervision is available at my expense.

Belmont reserves the right to treat my pet for fleas, ticks, lice, ear mites or worms if found today, at my expense.

I am aware that the practice of veterinary medicaine is not an exact science and thus, there are no guarantees for successful treatment. I understand there are cetain risks and complications associated with sedation, anesthesia, and/or any operation/procedures, unforeseen conditions may arise that may necessitate the perfromace of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian. I accept that my financial obligations remain regardless of the outcome and payment is due at time of patients discharge.

I am aware that payment is required at the time of services and due upon checkout. Treatment of my animal is determined by my decisions, with consideration of my financial resources. Any collection expenses, are my, the owner, responsiblity. Belmont Veterinary Center accepts the following type of payments: Cash, Check, Visa, Mastercard, American Express, Discover, Care Credit, AllPet, Scratch Pay.

In the event that your pet should experience cardiac or respiratory arrest while in the hospital today, do you give consent for resuscitation efforts to be initiated until you can be contacted further and notified of your pets status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor's discretion.

I agree to CPR being performed in case of arrestI elect "Do Not Resuscitate" in the case of arrest

For Dogs:

It is the owner's responsibility to maintain contraol of their pet at all times within and outside of Belmont Veterianry Center. All dogs must remain on a leash AND be kept near their owner at all times. It is also the responsibility of the owner to give warning to the staff if their pet may be jostile toward people and or other animals. If your animal should show aggression towards people/staff or other animals it is the right of the staff to restrain and apply a muzzle to your animal for personal protection.

For Cats and other small animals:

All cats and other small animals must be trasnported within a cage or carrier. If your pet shows aggression towards staff or other animals it it the right of the staff to restrain and apply a muzzle to your pet for personal protection.

The clinic and staff are to use all reasonable precaution againsit injury, escape, or death of my pet. The clinic staff will NOT be held liable for any problems that develop provided reasonalbe care and precautions are followed.

I understand that ANY problem that develops with my pet while I am absent will be treated as seen fit by the veterinarian and staff, I the owner, assume full responsibility for threatment expense involved.

I have read and understand this authorization and herby accept and agree to the term of the consent for treatment.

Signature

Today's Date of Signature

Date