Surgery Consent Form
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Owner Name
First Name
Last Name
It is imperative that we be able to reach you in a timely manner while your pet is with us today. Please list your cell phone below and be readily available to talk.
Owner Phone Number
Pet Name
Requested Procedures
Authorizations
Your pet will have an intravenous catheter placed for the procedure(s). The use of intravenous fluids during surgery facilitates adequate cardiovascular performance, reduces stress on the heart, assists in maintaining your pet’s temperature, hydration and blood pressure, and reduces the time it takes for your pet to recover from anesthesia. While undergoing these procedures your pet will receive anesthetic drugs that prevent pain. Because we care about your pet’s comfort and strongly believe that pain relief is important, additional pain medications will be provided, as needed, to control the level of your pet’s discomfort after surgery and during its recovery. I am the owner (or authorized agent of the owner) of the animal described above, and have the authority to execute this consent. I understand that some risk always exists with anesthesia, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian and understand that it may be necessary to provide additional medical or surgical treatment to my pet in the event of unforeseen circumstances. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. I hereby authorize the use of anesthetics and other medications, as well as any such additional treatment, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read, and fully understand, this consent. The fees associated with these services have been explained to me, and I agree to pay such fees at the time my pet is released from the hospital.
I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize treatment of my pet to be performed by Orange Canyon Pet Clinic. 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 as directed by the veterinarian
Initial
I have been advised as to the nature of this procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any sedation or anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. This risk includes serious bodily injury or death. I understand that it may be necessary to provide medical and/or surgical procedures which are 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 as are necessary in the veterinarian’s professional judgment. I accept responsibility for any result in additional charges.
Initial
I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital).
Initial
In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference:
Please proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred (starting range of $150-300).
Please do not proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred.
I acknowledge my choice regarding resuscitation choice for my pet as noted above.
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