Surgery Consent Form

Drop-Off time for Surgical Proceedures is from 7:00am-8:30am. Please plan on being in clinic for about 15 minutes, as the technician will ask a few questions at check-in.

Please make sure to pick up any food and water after midnight the night before, and do not feed breakfast the morning of the Surgical Proceedure.

*EXOTIC pets : Please call us at 281-231-9430. Some patients do need to eat before, and immediately after their surgical proceedure.*

Owner's Name

First NameLast Name

Email

example@example.com

Primary Phone Number

Please enter a valid phone number.

Secondary Phone Number

Please enter a valid phone number.

Patient's Name

Sex

FemaleMale

Procedure Date

Date

Procedure

Is this a dental procedure?

YesNo

If option 2 is selected above, I understand that my pet may need additional anesthetic procedures/dental care in the future at my expense. *

Agree

If this is a dental procedure, you agree that extractions may be required at additional cost. Teeth are not extracted unless medically needed.

Agree

Will the procedure involve a mass removal?

YesNo

Would you like the mass biopsy?

YesNo

Type a question

We offer a new very safe procedure using Florescent Light Therapy so that post surgery you will see the following results: Accelerated healing time, Reduction of time of cone use, Reduction of inflammation and Reduction of medications needs post surgery. Is this something that you would like to try for $15?

YesNo

All patients receiving treatment that are not current on their annual wellness will required to have an annual wellness exam performed and cost associated will be added to the invoice.

Agree

Has your pet had any vomiting, diarrhea or coughing within the last 10 days?

YesNo

Has your pet ever had seizures?

YesNo

Is your pet allergic to any medications, anesthetics or vaccines?

YesNo

Is your pet presently on medication(s) including supplements and over the counter medication (i.e. aspirin, Benadryl, etc.) ?

YesNo

If yes, what medication and when was it last taken?

If fleas and/or ticks are found on your pet while in the clinic, they will be treated at an additional cost to you

Agree

Like you, our greatest concern is the well-being of your pet. The early stages of many diseases are often asyptomatic, a physical exam alone my not identify all of your pet's health problems. Pre-anesthetic testing allows us to screen for hidden problems and can indicate imbalances that could affect your pet under anesthesia. Testing can alert your veterinarian to possible increased risks.

Pre anesthetic blood work highly encouraged on all pets over the age of 7 years.

I would like to have a Pre-Anesthetic performed on my pet.

YesNo

Please select one of the blood panel that you would liked performed.

ECG $38Mini $122 - Includes CBC, liver, kidney, glucose, total protein and ECGComprehensive $223 - Includes CBC, full chemistry profile and ECG

I understand the risks of using anesthesia. I understand it is against medical advice to decline pre-anesthetic testing. I have elected to refuse the recommended testing at this time an request that you proceed with anesthesia. I assume full responsibility for my pet.

Agree

Many patients require an e-collar immediately after waking from anesthesia due to excessive licking, chewing or scratching at the surgery site. To ensure proper recovery we ask that you pre-approve your pet's e-collar.

Would you like to purchase an E-Collar?
Yes No

A microchip can be placed under anesthesia with no additional discomfort.

Would you like to add on an microchip?
Yes
No

I agree to make myself available by telephone during the approximate time interval of 8:30 am to 5:00 pm.

I have read and understand

I agree to pay today, in full for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. Furthermore, I understand that regardless of the outcome of the procedures I am responsible for payment of the procedures immediately.

I have read and understand

Anesthesia

Pre-surgical blood tests and physical exam will enable us to assess and minimize the risk of anesthesia to your pet.

Monitoring

To minimize anesthesia risk, we monitor the heart, blood pressure, respiration rates, temperature, and oxygenation.

Catheterization

For sterility, hair will be shaved over a vein on the leg so that an intravenous catheter (I.V.) can be placed. Blood pressure may lower during anesthetic procedures and fluid therapy aids in supporting your pet’s internal organ systems. It also allows immediate access to the vascular system in case of an emergency.

Pain Management

This may be necessary for some procedures. The doctor will administer pain medications according to your pet’s needs.

As the parent, I hereby consent and authorize the performance of the following procedures/treatments.

Courtesy nail trimEar cleaning - $32Anal gland expression - $26Ear hair removal - $34

In the event that your pet should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitation efforts to be initiated until you can be contacted further and notified of their 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. Please select your choice below.

I agree to CPR being performed in case of arrestI elect a “Do Not Resuscitate” status in case of arrest

While Clear Creek Forest Animal Hospital provides the highest quality of anesthesia monitoring, surgical services, and dentistry, I completely understand the possibility of unforeseen complications that may occur during any associated anesthetic, surgical procedure, or dentistry. I fully acknowledge and understand these medical risks. I recognize that the veterinarian and hospital staff will do all that is necessary to minimize such risks. I will hold harmless Clear Creek Forest Animal Hospital, the veterinarian, or any hospital staff member liable for any complications that may or should arise in my pet’s medical treatment and care.

I have read and understand

I understand that during the performance of the procedures/treatments, unforeseen conditions or problems may be revealed that necessitates an extension of the procedure(s) or that different procedures than those set forth above may become necessary. Therefore, I consent to and authorize the performance of any such procedure(s) the veterinarian deems necessary. The staff of Clear Creek Forest Animal Hospital will contact me as soon as medically able to inform me of any changes in my pet's condition.

I have read and understand

I also authorize the use of appropriate anesthetics and other medications, and I understand the hospital support personnel will be employed as deemed necessary by the veterinarian.

I have read and understand

I understand that the hospital is not liable for any lost or damaged personal property (leashes, collars, etc) that are left in the hospital.

I have read and understand

If I neglect to pick up my pet within 5 days of the date below and do not notify Clear Creek Forest Animal Hospital within that time frame, Clear Creek Forest Animal Hospital may assume that my pet is abandoned.

I have read and understand

No warranty or guarantee has been offered or given to me as to the results or cure afforded by these treatments or procedures.

I have read and understand

I AM AT LEAST 18 YEARS OF AGE. I have read and understand this authorization and have the authority to execute this consent.

I have read and understand

I have read and fully understand this anesthesia and surgery consent form.

Signature

Date

Surgery Consent Form

General Patient Information

Pre-Anesthetic Bloodwork Authorization

E-Collar Authorization

Microchip Authorization

Owner Responsibility

Hospital and Procedural Information

CPR

Authorization