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Surgery/Dental Consent Form

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Surgery/Dental Consent Form

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

Client Name *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Patient Name *

Species

Sex

Patient History

Has your pet had any medications in the past 3 days? *

Has your pet experienced any trauma in the past 6 months (stepped on, hit by car, fallen, fights, etc.)? *

Has your pet been coughing, wheezing or sneezing? *

Does your pet have allergies? *

When was the last time your pet ate? *

When was the last time your pet was in-heat or bred? *

***DISCLAIMER*** There is an increased risk associated with spaying female pets whom have been in-heat within the past 8 weeks. It takes approximately 6-8 weeks from the first external signs of estrus for the body to return to a homeostatic state, with blood vessels returning to a “normal/ smaller” size without the progesterone influence from being in estrus. If you choose to proceed, we will exert all precautions necessary to ensure your pet has the safest procedure we can provide given the circumstance. However, this will lead to an increase in cost beyond your estimate. Post- operative complications, including bleeding and delayed healing are possible.*** *

I have read and understand.

Pre-anesthetic Blood Tests: We require blood tests within 30 days of all anesthetic procedures to assess organ function and to potentially highlight any issues that could complicate the effectiveness and safety of both the anesthesia and surgical procedure. Testing is recommended by our veterinarians based upon patient age. Our senior citizen patients (over the age of 7 years), require more in-depth testing as this age group are more susceptible to various conditions. Should an abnormality exist, we will assess the bloodwork, in conjunction with a complete physical examination, and work with you to develop and decide on the next best steps to ensure your pet’s best health. All dogs not tested within the last 12 months or not current on taking heartworm prevention are required to have a 4DX test to screen for Heartworm Disease, as well as tick-borne illnesses including Anaplasmosis, Ehrlichiosis and Lyme Disease. A Feline Triple Test is required for all cats that have never been tested or unvaccinated outdoor cats that have not been tested within the last year. This test screens for Heartworm Disease, Feline Leukemia Virus and Feline Immunodeficiency Virus. According to the age of your pet, your pet will receive: *

Under 7 years of age – Complete Blood Count, 10-panel Chemistry, Electrolytes
Over 7 years of age – Complete Blood Count, 17-panel Chemistry, Electrolytes

Other Services to be Performed:

Microchipping
Clean Ears
Express Anal Glands
Sanitary Clip

Surgical Site Protection: We require all soft tissue surgeries to go home with either an Elizabethan Collar, Inflatable Collar or a Pet Medical Shirt to protect the integrity of the surgical incision site.

Elizabethan Collar
Inflatable Collar
Pet Medical Shirt

Dental Procedures: If your pet is having a dental procedure performed, we will perform dental x-rays to check for disease under the gums that cannot be seen on physical exam. Based on exam findings under anesthesia and x-rays, it may be necessary to extract loose, fractured, infected and/or diseased teeth. Extractions needed are based upon oral probing and dental radiographs. Extractions are charged based on one-, two-, or three-rooted teeth with a cap at $699 if there are numerous extractions necessary. Additional cost involved with extractions may also include but are not limited to additional anesthesia, equipment, pain medications and antibiotics. Please initial below if you would like us to perform any necessary additional dental procedures as recommended by the veterinarian or if you would like us to contact you before proceeding. We will make every attempt possible to contact you, but if we are unable to make immediate contact with you, we will proceed in the best interest of the patient, and you will be responsible for any additional costs as follows: *

Please perform additional dental procedures as deemed necessary by the veterinarian. I understand that I am responsible for any additional cost for these procedures.
Please contact me before performing any additional dental procedures.

Anesthetic Monitoring: Your pet will have the latest technology and monitoring protocols while under anesthesia. Vital parameters, oxygenation, blood pressure and EKG monitoring is continually monitored and evaluated by our veterinary technicians during surgery. *

I have read and understand.

IV Catheter: Your pet may have an IV catheter placed prior to surgery. If an IV catheter is placed, your pet will have a shaved area on their forearm. The IV catheter is utilized to administer medications and/or intravenous fluids during the anesthetic procedure. Fluid therapy is vital to support hydration status and blood pressure when a patient is sedated. An IV catheter allows secure venous access in the event emergent, life-saving measures are needed. Your pet may go home with a bandage from the IV catheter. This can be removed when you get your pet home. *

I have read and understand.

CPR: If your pet should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of your pet’s 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 veterinarians discretion. Please initial your choice below: *

I agree to CPR in case of arrest
I elect a “DO NOT RESUSCITATE” status in case of arrest

AUTHORIZATION AND CONSENT *

I, the undersigned owner or authorized agent of the animal named above, hereby authorize the veterinarians of Grand Avenue Veterinary Hospital, and their assistants, to administer such treatments and to perform such procedures as listed above, including the administration of general anesthesia. I also authorize the use of such anesthetics as determined to be necessary for the above-mentioned procedure(s). I understand that during the performance of this procedure, unforeseen conditions may be revealed that necessitate an extension or variance in the procedure(s) set forth above. I expect the veterinarians of Grand Avenue Veterinary Hospital to use reasonable care and judgement in performing the procedure(s). The nature of the procedure and risks involved have been explained to me, including death, and I understand results cannot be guaranteed. I am also aware that unforeseen complications, including death, resulting from the procedure(s) will not relieve me from any obligation to all reasonable costs incurred regarding this animal.

I am aware that payment is required at the time of service and due upon checkout. Treatment of my animal is determined by my decisions, with consideration of my financial resources. If any charges are not paid when due, interest will accrue at 2.0% per month. Any collection expenses, including attorney fees, are my (the owner’s) responsibility. Grand Avenue Veterinary Hospital accepts all major credit cards, Care Credit and Scratch Pay. I also understand it is my (the owner’s) responsibility to know what my pet insurance will cover with regard to my pet’s medical expenses. *

I have read and understand.

I understand that I am encouraged to discuss any concerns I have about those risks with the veterinarian before any procedure is initiated. *

I have read and understand.

Would you prefer a text or a phone call? *

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Date *

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Surgery/Dental Consent Form

Surgery/Dental Consent Form

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