Midvalley Animal Clinic Surgery Release Form

Pet Name

Date of surgical/dental appointment:

Date

Your First and Last Name:

First NameLast Name

Email

example@example.com

Primary Contact: Who should we contact when your pet is ready?

Contact Phone Number

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

Alternative Contact Name

This must be different than the number above and in case you are not available.

Alternative Contact Phone Number

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

Preferred Method of Contact (This is where we will contact you about updates or when your pet is ready to go home).

Primary procedure we are performing on your pet

Are we performing another procedure?

Second procedure we are performing on your pet

Spay or Neuter consent

By checking this box, I understand I am giving Midvalley Animal Clinic permission to sterilize my pet regardless of whether the the sex was stated incorrectly, has retained testicles, is in heat, or is pregnant. I understand there may be additional charges and agree that I am responsible for these fees at time of service. I hereby release Midvalley Animal Clinic and it's veterinarians, technicians, assistants, directors, employees, and volunteers from any and all claims arising out of or connected with the performance of this procedure. I understand that all post-surgical instructions must be followed as instructed and if any additional care (i.e. antibiotics or incision repair) or medications are necessary post-operatively, that I will be responsible for the cost of care or medication.

Bloodwork Midvalley Animal Clinic requires pre-anesthetic blood testing on all pets undergoing any surgical procedure. Your vet will gain important information to detect underlying health issues and evaluate your pets overall health. Even seemingly healthy animals may have health problems that can make surgery risky and/or recovery more difficult.

Puppies normally have 28 baby teeth, and adult dogs have 42 permanent teeth. Kittens have 26 baby teeth, and adult cats have 30 permanent teeth.

As adult teeth erupt, the roots of the baby teeth are usually resorbed so the baby teeth can fall out. When they do not fall out as expected, they are called retained deciduous teeth or persistent baby teeth.

Retained baby teeth can cause overcrowding, plaque and tartar buildup, abnormal positioning of the adult teeth, and periodontal disease. Two teeth should not occupy the space meant for one.

If retained baby teeth are present, we typically recommend removing them after 6 months of age, often at the time of a spay or neuter procedure. Removing them early gives the adult teeth the best chance to move into a normal position and helps prevent future dental problems.

Source Information - Veterinary Partner

Do you give Midvalley Animal Clinic permission to extract any retained deciduous teeth? There is a fee for each deciduous tooth removed.

Dental Procedure Consent

By checking this box, I authorize my pet to be placed under general anesthesia to have a dental procedure today. I understand as a part of this dental procedure, a veterinarian and/or trained veterinary staff member will assess my pet’s oral health with the use of radiographs, probing depths, and a complete visual examination to determine if any extractions, surgical flaps, suturing, medications, or additional surgical procedures are required. I understand that a trained veterinary staff member will perform the scaling, polishing, extracting, suturing, and medical charting of my pet’s teeth under the supervision of a veterinarian. I understand there are several factors in determining if a tooth should be extracted including dental disease, the overall health of my pet, and the age of my pet. I understand that I have the option to pursue evaluation or treatment by a veterinary dental specialist prior to this procedure, and that a referral to a specialist may also be recommended based on findings. I understand that there are risks involved with any animal undergoing anesthesia and/or surgery and that risks or complications are also possible during the recovery of anesthesia. The nature, risks, and estimated costs of this procedure have been explained to me. By signing this consent form, I acknowledge that my questions have been answered to my satisfaction and I authorize the veterinary team to proceed.

Mass / Lump Removal Procedure Consent

I understand I am giving Midvalley Animal Clinic permission to remove the lump(s)/mass(es) that I have marked on this form and that I have marked on my pet. I understand, if there are additional lump(s)/mass(es) located outside of the original exam that I would like to have removed, there will be additional charges and agree that I am responsible for these fees at time of service. The Veterinarian will only remove masses that are marked on your pet and on the body map below. When your pet is having a lump/mass removed it is very important that you mark the lump(s)/mass(es) on your pet prior to their surgery appointment so we are aware of which lump(s)/mass(es) you wish to have removed. This can be done with a permanent marker, waterproof mascara, painter's tape, or carefully clipping a small amount of hair with clippers (not scissors).

How many lumps/masses are we removing?

Please select the species of your pet to generate the appropriate body map to mark the lumps / masses

Canine Body Map - Mark the location of each lump/mass that you want removed.

Canine Body Map notes (optional)

Feline Body Map - Mark the location of each lump/mass that you want removed.

Feline Body Map notes (optional)

Histopathology/Biopsy Testing

Mass or tumor removals are not uncommon in dogs and cats. These masses grow in or around a major organs, under skin (subcutaneously) or apart of the skin. These masses or tumors can be benign or malignant. Malignant tumors have a higher chance for recurrence, spread to other parts of the body, or have impaired healing and need a wider margin of excision than benign tumors. Therefore; the incision may be much larger then the mass itself. Unfortunately, sometimes it is impossible to get a definitive diagnosis without removal and histopathology. Even with aggressive surgery, these tumors occasionally re-grow and need further surgery. Rarely, the tumor can be so invasive that complete excision is not possible without damaging the organs, nerves or blood vessels that lie near the mass. Histopathology reveals the types of cells present in abnormal tissue, permitting accurate diagnosis of the disease and helping determine appropriate treatment(s). Where cancer is involved, histopathology helps determine the aggressiveness of the cancer, which assists in coming to a decision how to proceed.

Please select quantity of masses to be submitted for histopathology/biopsy if recommended by the veterinarian:

TPLO Surgical Procedure:

To relieve the pain associated with the torn cruciate ligament and accompanying inflammation, the top portion of the tibia (lower leg bone) is osteotomized (cut) and rotated to a position that will produce less stress on the knee. Sometimes the medial and/or lateral meniscus (a shock absorber cartilage in the knee) is torn as well and must be removed or trimmed. Please be advised when this cartilage is torn, arthritis develops more rapidly, even after surgical removal. After surgery, your pet will need to go through periods of recovery to allow the bone to heal and will need to complete rehabilitation to regain strength and flexibility in the affected leg. In most dogs, the recovery and rehab periods can be up to 4 to 6 months before full return to unrestricted activity.

If you would like a visual of what a TPLO entails, this YouTube video demonstrates what a TPLO is and how we perform the surgery:

Youtube

Lateral Suture Repair Procedure:

The aim of lateral suture repair surgery is to place a strong suture that prevents the two bones from moving too far apart, so that the tibia does not shift forward during weight-bearing, and act in a similar fashion to the cranial cruciate ligament. After a period of healing, the soft tissues around the joint form scar tissue around the knee, which provides support in the same way as the suture. Over time, the suture itself will weaken but by this point the scar tissue should have taken over its role. After surgery, your pet will need to go through periods of recovery to allow the bone to heal and will need to complete rehabilitation to regain strength and flexibility in the affected leg. In most dogs, the recovery and rehab periods can be up to 4 to 6 months before full return to unrestricted activity.

If you would like a visual of what a Lateral Suture Repair Surgery entails, this YouTube video demonstrates what a TPLO is and how we perform the surgery (skip ahead to 4:30/**We do not offer TTA surgery):

Youtube

As with any surgery, there are complications that may occur with both anesthesia and the surgical procedure.

Possible Surgical Risks:

1. Infection (less than 3%) which may require additional testing and medication at an additional cost.

2. Blood clots that can lodge in major organs causing stroke or in rare cases, death.

3. Hemorrhage, especially from the popliteal artery.

4. Bruising and edema postoperatively.

5. Implant breakage or failure, requiring additional surgery at an added cost.

6. Fractures of the tibia or fibula bones.

7. Allergic reaction to the suture material utilized in the repair causing a seroma to form (small pocket of fluid) which usually resolve over time without drainage or revision.

8. Advancing arthritis that makes the joint stiff and sore, especially after exercise or in cold weather.

Strict adherence to post-surgical care and the proper medicating of your pet will minimize these potential complications. Serious problems are very uncommon in most cases.

Tibial Plateau Leveling Osteotomy (TPLO) / Lateral Suture Repair Procedure Consent

By checking this box, I authorize my pet to be placed under general anesthesia to have a TPLO / Lateral Suture Repair procedure performed today. I understand that there are risks involved with any animal undergoing anesthesia and/or surgery and that risks or complications are also possible during the recovery of anesthesia. The nature, risks, and cost of this procedure have been explained to me and I understand my signature on this consent form indicates that my questions have been answered to my satisfaction.

Prolapse of the Tear Gland of the Third Eyelid “Cherry Eye”

Dogs and cats have a third eyelid that contains an important tear gland. This gland helps produce a significant portion of the eye’s tear film. In some pets, the tissue holding this gland in place is weak, allowing the gland to prolapse or “pop out.” This is commonly called cherry eye and appears as a red or pink swelling at the inner corner of the eye.

The goal of treatment is to return the gland to its normal position when possible, while preserving tear production and reducing the risk of future dry eye.

Option 1: Surgical Replacement/Tacking of the Gland

This is the cherry eye repair procedure performed at Midvalley Animal Clinic. A permanent suture is placed to hold the gland back in its proper position.

Possible risks and complications include postoperative swelling, inflammation, discomfort, irritation from the suture, recurrence of the cherry eye, or the need for additional surgery. Cherry eye repair is known to have a risk of recurrence, and some pets may require a second procedure or referral to a veterinary ophthalmologist.

Some swelling after surgery is expected, but the eye should become more comfortable and improve in appearance within about a week. If the eye becomes suddenly painful, very swollen, abnormal in appearance, or if the cherry eye returns, the pet should be rechecked as soon as possible.

Option 2: Imbrication/Pocketing Procedure

The imbrication, or pocketing, procedure is another surgical technique used to reposition the gland. This procedure involves creating a small pocket of tissue to help hold the gland in place.

Midvalley Animal Clinic does not perform the imbrication/pocketing procedure. If you are interested in this option, or if a previous cherry eye repair has failed, we recommend consultation with a veterinary ophthalmologist.

Option 3: Removal of the Gland

Removal of the third eyelid tear gland is another treatment option for cherry eye. This procedure removes the prolapsed gland rather than repositioning it.
Because this gland contributes to normal tear production, surgical replacement is generally preferred when possible. Once the gland is removed, it cannot be replaced. Some pets may continue to produce enough tears from the remaining tear gland, while others may have an increased risk of developing chronic dry eye later in life.
Dry eye can cause discomfort, thick eye discharge, corneal irritation, pigmentation, vision changes, and may require long-term or lifelong eye medication. For this reason, gland removal is usually reserved for cases where replacement is not successful, not feasible, or has been discussed in detail with the veterinarian.

Source Information - Veterinary Partner

I have read and understand the risks and benefits associated with the surgical options provided and request to have the following procedure performed on my pet:

I consent to removal of the prolapsed third eyelid gland at Midvalley Animal Clinic. I understand that surgical replacement is generally preferred when possible to help preserve tear production. I understand that removal of the gland may increase the risk of chronic dry eye, discharge, discomfort, vision changes, and the possible need for long-term or lifelong eye medication. I understand these risks and still wish to proceed with gland removal.

Has your pet been diagnosed with a medical condition (example: heart murmur, epilepsy, cushings, diabetes, etc.)?

Medical Condition 1

Is your pet being treated by another veterinary clinic?

Name of veterinary clinic

Does your pet take any medications or supplements?

List your pet's medications, doses, and when last given:

Is your pet allergic to any medications or vaccinations?

Please list what medications or vaccines your pet is allergic to:

Be sure to include what symptoms your pet experienced during the reaction.

Would you like any additional services performed while your pet is here? All additional services will result in additional charges.

Anal Gland Expression

Anal gland expression is the process of manually emptying the anal sacs, which are small scent glands located on either side of the rectum.

$40.00

Nail Trim with Surgery

A basic nail trim performed by our trained staff to help keep your pet’s nails at a comfortable length.

$25.00

DHPPL Vaccine (Canine)

Distemper, Hepatitis, Parainfluenza, Parvovirus, Leptospirosis

$43.00

Bordetella Vaccine (Canine)

Bordetella bronchiseptica

$40.00

Rabies Vaccine (Canine/Feline)

Rabies

$30.00

FVRCP Vaccine (Feline)

Feline Viral Rhinotracheitis, Calicivirus, Panleukopenia

$40.00

FeLV Vaccine (Feline)

Feline Leukemia

$48.00

Influenza Vaccine (Canine)

H3N2 and H3N8

$48.00

Microchip Implant

HomeAgain microchip implant that includes 1 year of registration.

$75.00

Total

To ensure the safety of our staff and patients, it is required that all pets are current on their rabies vaccination.

If you have had this vaccine done elsewhere, you must provide proof of a valid documentation or a rabies certificate. If you cannot provide valid documentation or a rabies certificate, the vaccine will be required to be administered during your appointment.

Per state law, we do not make exceptions for indoor or elderly pets. The only exception is if our veterinarian determines the pet is too ill to be vaccinated at this time, in which case a plan will be established to ensure compliance as soon as the pet is healthy enough.

Type a question

Please upload your rabies documentation here or bring them with you to the appointment.

We may use an advanced vessel-sealing device during your pet’s procedure. This tool helps seal blood vessels and tissue quickly and securely, reducing surgical bleeding and improving safety.

In some procedures, this device is required due to the risk of bleeding or complexity of the surgery. In these cases, its use is considered medically necessary and will be utilized regardless of client preference to ensure the safest outcome.

For other procedures, this device may be optional, and you may choose whether to include it for an additional fee of $125. The attending surgeon will determine whether the device is required or optional at the time of surgery, based on your pet’s anatomy and surgical findings.

Benefits include:

Reduced bleeding during surgery
Shorter surgical time, which means less time under anesthesia
Improved precision and reduced trauma to surrounding tissues
Faster healing and more comfortable recovery

Mandatory for:

Splenectomy
Liver biopsy
Mass removal involving large vessels or significant blood supply
Mastectomy or mammary chain removal

Recommended for:

Spay (especially in heat, pregnant, or large-breed adult dogs)
Gastrotomy / Enterotomy
Large soft tissue mass excisions

Not recommended for:

Regular Neuter

There is an additional $125 fee for the use of this technology.

Vessel-Sealing Device Consent - If the surgeon determines it’s appropriate for your pet's surgical procedure, would you like us to use the device during your pet’s procedure for an additional $125

Anesthesia and pain can cause nausea. We have an injectable medication that can be given to your pet to help relieve these side effects called Cerenia. This injection lasts 24 hours. The price for this injection is based on the size of your pet.

Select the weight of your pet for estimated cost. **Please note if you do not know the exact weight of your pet or if they weigh differently than you selected, we will administer the correct dose based on the actual weight. **

Would you like your pet to have a Cerenia injection?

We offer a local anesthetic called Nocita that is used to numb the incision site for 3 days to reduce pain or discomfort. This injection is not recommended for lumps/masses suspected of being malignant (cancer).

The price for this injection is based on the incision, procedure and size of your pet.

Select the weight of your pet for estimated MAXIMUM cost. The pricing provided accounts for the maximum approved dose, which may not necessarily be what is administered based off the doctor recommendation. **Please note if you do not know the exact weight of your pet or if they weigh differently than you selected, we will administer the correct dose based on the actual weight.**

Estimated weight range for Nocita pricing

Would you like us to use Nocita?

Some patients require a sedative after surgery. While healing, the goal is to prevent rough play or hyper activity which may harm the incision. The price for a sedative is based on the size/activity level of your pet and may vary beyond the estimate provided below. Please ask for a more specific estimate for your pet.

Would you like us to send home a sedative?

For certain surgeries, we offer a comfortable, reusable, machine washable medical pet shirt that fits snug over the incision to prevent licking, chewing, or scratching while your pet heals. Often times this shirt can be used in place of a cone but sometimes would be recommended in addition to the cone. The cost is based on your pet's size and ranges between $30-$35.

**Please note, these shirts do not work with feline neuter incisions. **The color and pattern may vary.

Would you like us to fit your pet for a medical pet shirt?

Are you leaving any items with your pet (example: blanket, toy, leash, carrier)?Please note: All blankets, bedding, or other kennel accessories will be provided for your pet during their stay. If you choose to bring something anyways, please remember, after surgery can be messy and your items may become stained or damaged.

CPR - Cardio Pulmonary Resuscitation is the treatment provided for a pet who has stopped breathing or whose heart has stopped beating. Resuscitation of a pet who has stopped breathing (but still has a heartbeat) is more likely to be successful than a pet who has no heartbeat.

DNR - Do Not Resuscitate means that if a pet stops breathing or his/her heart has stopped, no effort should be made by our veterinary professionals to attempt to revive the pet, and the pet will be allowed to die.

In the event of a medical crisis:

I am the owner, or authorized agent of the owner of the pet presented for care.

I have been advised of the nature of the procedure mentioned above and the risks involved in performing these procedures. I hereby and forever release the doctors and staff at Midvalley Animal Clinic of Taylorsville, Utah from any liability arising from anesthesia and surgery on the aforementioned animal.

I authorize Midvalley Animal Clinic to do the preceding services on my pet. I understand the following (1) No guarantee of successful outcome of treatment is either expressed or implied. (2) Risks are involved in the treatment of any condition including death.

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(s) as directed by the veterinarian.

I understand that it may be necessary to provide medical and/or surgical procedures 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 necessary in the veterinarian’s professional judgment. I accept responsibility for resulting in additional charges.

I agree to be responsible for charges incurred while my pet is in the care of this facility and understand payment is due when my pet is released back to my care. I understand all fees for services rendered are payable by cash, check, or credit card at the time services are rendered. I understand any past due accounts are subject to all costs of collection, including legal fees.

I understand there will be no staff to attend to my pet overnight (1) should I fail to pick up my pet before closing, I agree that I am financially responsible for any boarding, additional medications administered, or treatments performed by the staff to care for my pet (2) if my pet requires special overnight care recommended by the veterinarian and I have declined referral to a 24-hour hospital.

I have agreed to submit this application by electronic means. By signing this document electronically, I certify under penalty of perjury and false swearing that my answers are correct and complete to the best of my knowledge, I also certify that;

I understand the questions and statements on this form.
I have read and understand the information.
I understand the risks for giving false information I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

Date

E-Signature

Midvalley Animal Clinic Surgery Release Form

Contact Information

Procedure Selection and Consent

Spay and Neuter Procedure

Pre-anesthetic Blood Screening

Retained (Deciduous) Baby Teeth Removal

Dental Procedure

Mass / Lump Removal Procedure

Tibial Plateau Leveling Osteotomy (TPLO) / Lateral Suture Repair

Third Eyelid Gland Surgical Treatment Options

Medical History and Current Treatment

Additional Services

Would you like any additional services performed while your pet is here? All additional services will result in additional charges.

Rabies Vaccination is Required for All Pets

Vessel-Sealing Device

Cerenia (Anti-Nausea Medication)

Nocita (Incision Anesthetic)

Sedative to Help with Post Operative Healing

Medical Pet Shirt

Consent for CPR or DNR

Authorization and Acknowledgement of Risk

Midvalley Animal Clinic Surgery Release Form

Contact Information

Procedure Selection and Consent

Spay and Neuter Procedure

Pre-anesthetic Blood Screening

Retained (Deciduous) Baby Teeth Removal

Dental Procedure

Mass / Lump Removal Procedure

Tibial Plateau Leveling Osteotomy (TPLO) / Lateral Suture Repair

Third Eyelid Gland Surgical Treatment Options

Medical History and Current Treatment

Additional Services

Would you like any additional services performed while your pet is here? All additional services will result in additional charges.*

Rabies Vaccination is Required for All Pets

Vessel-Sealing Device

Cerenia (Anti-Nausea Medication)

Nocita (Incision Anesthetic)

Sedative to Help with Post Operative Healing

Medical Pet Shirt

Consent for CPR or DNR

Authorization and Acknowledgement of Risk

Would you like any additional services performed while your pet is here? All additional services will result in additional charges.