Surgery and Treatment Consent

Surgery and Treatment Consent
CLIENT/ PATIENT INFORMATION:
Client Name*

First NameLast Name
Patient (Pet) Name*
Species*
Breed*
Gender*
Color
Age*
Items Left With Pet
HOSPITAL POLICIES:

PLEASE READ THE SECTION CAREFULLY:

VACCINATION POLICY: Our hospital recommends that your pet be current on their distemper and rabies vaccinations. WE require that in-patients be current on rabies. Proof that a rabies vaccine has been given by a veterinarian is required at admission. If your pet is overdue for the rabies vaccine, it will be updated pending confirmation of your pet’s health.

FLEA POLICY: Pets with fleas will be treated in the clinic at additional cost.

PAIN CONTROL: All patients undergoing a surgical procedure will receive pain medication, to be given at home, to ensure their comfort.

SURGICAL FOLLOW-UP POLICY: Surgeries that are not routine may require additional visits. There may be additional fees for these visits. We do not include these fees in the surgery cost since there may be more than one recheck.
REASON FOR VISIT/ SCHEDULED PROCEDURE(S):
Check ALL that apply*

Spay (female)Castrate (male)Laser DelcawDental CleaningOther Anesthetic Procedures (please elaborate below)
If "Other Anesthetic Procedures", please elaborate
ANESTHESIA SUPPORT SERVICES:

When general anesthesia is used for your pet’s surgery or procedure, it is not without risk. To maximize their care and safety we may recommend your pet receive the supportive services below. Depending on your pet’s age, some of these we may require. Complete descriptions of each are on the back. Keep in mind these services are at an additional cost, estimates are available upon request. Please clearly accept or decline the following services.
Pre-Anesthetic Testing (Choose 1): Blood work to assess your pet's internal health before general anesthesia*

Chem 10: Highly recommended for all pets under age 6Chem 17: Highly recommended for all pets, for a more complete screening, and REQUIRED for all pets over age 6I DECLINE the pre-op blood testing that is recommended, but please perform the procedure
IV Catheter/ Fluids (Choose 1): Support for kidney function and immediate intravenous access in case of an emergency. **This service may be REQUIRED for certain lengthy procedures.*

YES - Please place an IV catheter. (Required for pets 6 years & older)Yes - REQUIRED for pets over 6 years of ageNO - I DECLINE to have an IV catheter placed
EKG (Choose 1): Recommended for ALL pets, to access your pet’s heart health*

YES - Please perform an EKG on my pet, to access his/her heart healthNO – I DECLINE an EKG at this time
Anti-nausea Relief: Relief for nausea and/or vomiting associated with anesthetic procedures. May also help patient return to eating faster. **This medication may be required for some procedures.*

YES - I want my pet to have this medication for potential nausea or vomiting associated with anesthesia.NO - I do not want my pet to have this medication for potential nausea or vomiting associated with anesthesia.
Therapy Laser (Choose 1): Aids in healing and patient comfort by reducing pain, inflammation, and swelling. ***** Laser Therapy is NOT recommended for most mass removal surgeries. ****

YES – Please perform Laser Therapy on my pet to aid in healingNO – I DECLINE Laser Therapy at this time
E-COLLAR: (Choose 1) An Elizabethan collar provides protection from your pet licking, scratching, and rubbing the surgical area and causing damage and/or infection. *

YES - Please provide andfit my pet for an e-collarNO - I DECLINE an E-collar at this time
Microchip ID (Choose 1): Best time for microchipping! Includes chip, implantation, and 1st year of enrollment with HomeAgain®.*

YES - I want my pet microchipped while under anesthesiaNO - I do NOT want my pet microchipped while under anesthesia
ADDITIONAL SERVICES OFFERED:

Please select , BELOW, the procedures you WOULD LIKE PERFORMED today.
Please check ALL that apply*

Intestinal Parasite ScreeningEar CleaningFelv/FIV TestRabies VaccineKennel Cough VaccineHWT (heartworm test)Anal Gland ExpressionNail TrimDistemper VaccineFeline Leukemia VaccineMicrochip IdentificationDewormingFlea & Tick PreventionHeartworm PreventionOther (please elaborate below)
If "Other", please elaborate
Prescription(s) Refill Request
**Surgical Patients: Many of these services are less stressful and more comfortable for your pet if performed while they are under anesthesia.
CONSENT TO TREATMENT:

I am the owner or agent for the owner of the above-described animal and have the authority to execute this consent. I hereby authorize Heartland Veterinary Clinic to perform the procedure(s) listed above. I understand that during the performance of the foregoing procedure(s), unseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) that are set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarian’s professional judgment. I also understand that I will be responsible for full payment of services at the time my pet is discharged from the hospital.

I have read and understand this authorization and consent, and being of legal age, I hereby consent and authorize this hospital and its veterinarians and staff to perform the agreed to procedures.
- I have been advised as to the nature of the procedure(s) and/or surgery and the risks involved.
- I accept that anesthesia always involves some element of risk to my pet.
- I understand that every precaution is practiced to ensure the safety of my pet before, during, and after the procedure.
ESTIMATES AVAILABLE UPON REQUEST
EMERGENCY CONTACT NUMBER (1)*

Area CodePhone Number
EMERGENCY CONTACT NUMBER (2)

Area CodePhone Number
Date

MonthDayYear
Client Signature*

Clear
Please contact us with any questions as (540) 434-3903.
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