Surgical Consent Form

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Surgical Consent Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet before your visit.

Name *

First

Last

Phone *

Email *

Pet's Name *

Anesthesia

Procedures requiring anesthesia are always associated with a certain amount of risk. A pre-surgical exam and pre-anesthetic tests are performed on each pet to ensure safety during anesthesia. In recent years, general anesthesia has become safer with the advent of newer drugs and better patient monitoring. Some conditions may not, however, be evident on a physical exam. To ensure your pet's safety during anesthesia pre-surgical lab work is performed as an internal exam.

Pre Surgical Lab Work

Pre-anesthetic lab work is performed on every pet. The basic testing includes testing kidney function (BUN and Creatinine), liver function (Total Protein, ALT and ALKP), screen blood sugar levels (Glucose), and packed cell volume (PCV) to determine hydration status and detect anemia. Geriatric pets over the age of six will need to undergo a surgical senior comprehensive chemistry panel and complete blood count. Pets with abnormal physical findings or illness will need additional lab work to ensure their safety.

Comprehensive Chemistry and CBC - Tests kidney function, liver function, glucose, packed cell volume, electrolytes (Sodium, Chloride and Potassium), complete blood count (CBC), ALT, ALKP, BUN, Creatinine, Glucose, AMYL, Calcium, Cholesterol, ALB, Phos, TBIL, and total protein ($170).

Pre-surgical vaccine/testing requirements

All pets must be up to date on their Rabies and Distemper vaccine. Canines (7 months and older) must have had a Heartworm/Lyme/ Anaplasma/Ehrlichia test in the last 12 months. Felines must have had a Feline Leukemia/FIV/Heartworm test in the last 12 months. Pets that are overweight or in heat are subject to an additional surgical charge.

Fluids and Pain Management

We place an intravenous (IV) catheter in every patient to administer medications and fluids while under anesthesia. IV fluids will aid the body in stabilizing internal organs and blood pressure, and in metabolizing the anesthetic agent more efficiently. Along with shaving the hair at the IV catheter site, we may aíso shave other areas including the site for surgical prepping.

Your pet will be administered pain management drugs. Pain management drugs will allow your pet to have a more comfortable and faster recovery. We believe controlling our patient's pain is important. For that reason we will administer medication before, during and after your pet's medical procedure to control pain, reduce discomfort, and promote recovery. Research shows that pets recover faster and more completely when their pain is controlled.

We offer a Microchip Identification System. This procedure involves a small microchip implanted just underneath the skin in between the shoulder blades. If your pet is ever lost or stolen, this microchip aids greatly in the recovery of your pet. The cost for the microchip is $74.00. Select your choice. *

Yes, please microchip my pet.
No, I decline the microchip at this time.
No, my pet has already been microchipped.

If your pet is having a dental procedure performed, please read and initial the following:

Factors that limit our ability to detect every dental problem your pet may have with an oral exam many include: lack of patient cooperation which can impair visualization (especially back teeth), many periodontal problems can only be detected with dental radiographs or by probing under the gum with an instrument; dental tartar can hide underlying cavities or fractures. *

Do whatever is needed to give my pet a healthy oral cavity including tooth extractions, gingivectomy, and/or oral mass removal.
Do only what I have authorized.
Please contact me before doing any additional procedures. If I cannot be reached while my pet is under anesthesia then perform whatever procedures are needed.

Should an emergency situation arise requiring procedures in addition to or different from thie now contemplated, I further request and authorize Douglas Animal Hospital Staff to do whatever she/he deems advisable. I consent to the administration and use of anesthesia. I agree to pay in full for all services rendered, including those deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. The nature and purpose of the procedures, possible alternative methods of treatment, risks involved, and the possibility of complications, including death, have been fully explained to me. *

I have read and understand.

Signature *

Date *

Surgical Consent Form

Surgical Consent Form

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