Account #: _____ pets undergoing surgery:9. Additionally, pain medication may be prescribed to take home. Secondary Services Offered to Surgical Patients Your pet has been admitted to the Animal Clinic today for the procedure listed on the front of this Consent Form. If your pet is having a dental surgical procedure completed, please fill out the below form and it will be sent to us for review. Cities and Zip Codes served by Russell Ridge, Cities and Zip Codes served by Hamilton Ridge, Cities and Zip Codes served by Apalachee Ridge, Cities and Zip Codes served by Camden Village. surgery, older age, pregnancy, heat, and diseases such as heartworms. We realize surgery and anesthesia can be an anxious time for both the owner and patient and we attempt to make surgery day as safe and comfortable for all involved. Georgia Veterinary Associates is a group of 4 privately owned animal hospitals in the metro Atlanta area. Consent form and waiver: I hereby request that Wellness Veterinary Clinic provide the service for my animal. INSTRUCTIONS This is an informedconsent document which has been prepared to help inform you - about blepharoplasty (eyelid) surgery, its risks, as well as alternative treatment(s). Your dog/cat will receive a small tattoo on their underside to show that they have been sterilized. Pet's Name. If you do not understand the instructions, please do not hesitate to ask. Important! The surgical consent form is used to ensure a patient has been provided with all the necessary information concerning a proposed surgery/special procedure, and that they agree to undergo the operation. *State of the art equipment enables us to perform the pre-anesthetic blood profile at our hospital and we are committed to making this technology available to our patients. ?§€:¢‹0ÂFB‘x$ !«¤i@ڐ¤¹ŠH‘§È[EE1PL”ʅ⢖¡V¡6£ªQP¨>ÔUÔ(j These conditions may not be detected without a pre-anesthetic profile thus not allowing for the most appropriate and safest anesthetic regime to be administered. Resource Articles ©2021 GeniusVets. As a result, all surgery patients will receive pain management before, during and after surgery. The Royal College of Veterinary Surgeons. We aim to enhance society through improved animal health and welfare. You should use this Veterinary Surgical Consent Form Sample instead of creating a consent form manually. I understand that it takes up to … Bleeding, Infection, Recurrent Heat, Urinary Incontinence, Weight Gain, Suture Reactions, Bleeding, Infection, Testicular Swelling, Suture Reactions, Bleeding, Infection, Limping/Lameness, Regrowth of Nail, Bleeding, Infection, Swelling and Drainage, Suture Reaction. Therefore, I herby consent to and authorize the performance of procedures or surgeries, as deemed necessary by the veterinarian. õMFk¢ÍÑÎè t,:‹.FW ›Ðè³èô8úƒ¡cŒ1ŽL&³³³ÓŽ9…ÆŒa¦±X¬:ÖëŠ År°bl1¶ On your pet’s surgery day, we require you to review and sign a Surgery/Anesthesia Consent Form in which you acknowledge understanding of this surgical information packet. I have been advised as to the nature of the procedure(s) or surgery and the risks involved. INFORMED CONSENT OTOPLASTY SURGERY Page 3 of 7 Patient Initials 05-09-09 version ©2009 American Society of Plastic Surgeons®. Additional information will be given at discharge. This allows us to have more control over anesthetic depth and it is less irritating to the airways. CAT AND DOG ANESTHESIA AND SURGERY CONSENT FORM. INFORMED CONSENT - BLEHPAROPLASTY SURGERY Page 1 of 6 Patient Initials 03-01-13 version ©2005 American Society of Plastic Surgeons®. ; Connect While your Acknowledgement and Consent of Surgical Risks As the owner, or agent of the owner of the animal above, I hereby give KKM Veterinary Clinic consent to perform surgery and/or treatments for my pet. This will ensure that your pet is able to receive oxygen and a gas anesthetic at all times and prevents aspiration of any fluids into the lungs. In the form, the pet owner must state the name of his pet … I understand the risks involved in my animal’s surgery … Once your questions and/or concerns have been addressed by the technician or veterinarian, the receptionist will take payment and schedule any post-surgical progress exam appointments or suture removal your pet may need. Consent Form (found at the end of this information - please scroll down to sign). _____ Additional Surgery Fees: I understand that if my pet is deemed to be in heat, pregnant or a cryptorchid there will be an additional fees ra nging from $22 to $60. Many times, owners will request that other services be addressed while their pet is in our care. As the owner of the above animal or the agent of the owner of the above animal, I hereby give my consent to the following surgical procedure(s): SPAY NEUTER DENTAL OTHER: _____ Any animal 5 years or older, and any animal presenting for a procedure other than spaying or neutering must have mandatory blood work done. Dogs may have a slight cough for a few days after surgery. The fluids also help provide support to the circulatory system by maintaining blood pressure and preventing dehydration, as well as aid in a quicker recovery from anesthesia. Date. Once your pet is in our care, a veterinary technician will escort your pet to the surgical/treatment area where our veterinarian will thoroughly examine your pet before he/she is prepped for their procedure. You can read more, International Travel and Health Certificate Form. I have read, understand and agree to follow all aftercare instructions provided by Wellness Veterinary Clinic. You should consider all of the… Surgery Consent Form Author: …I either certify that my dog currently vaccinated, waive my right to protect my dog by having it vaccinated, or I request recommended vaccinations at the time of surgery. Anesthesia/Dental Information. This informational sheet offers step-by-step instructions on how to desensitize a dog to a scary object (nail trimmers)or scary situation (nail trimming). Did You Fast your Pet Appropriately (No food After Midnight the Night Before)? We hope this program will reduce any discomfort experienced and aid in a quicker recovery. We do this by setting, upholding and advancing the educational, ethical and clinical standards of veterinary surgeons and veterinary nurses. Important Information Regarding Your Pet’s Surgery PLEASE READ CAREFULLY. Monitoring of patients during anesthesia is done in two ways. This form and your discussion with your doctor are intended to help you make informed decisions about your surgery. Any risks associated with the procedure and treatment thereafter must be outlined in the form. Owner's Name. Owner's Name: Patient's Name: Preferred Phone Number: Is Your Pet up to Date on Vaccines or Titers? If you have any questions or hesitations about the scheduled procedure, please do not hesitate to call us to discuss any aspect of the upcoming procedure. I realize that results cannot be guaranteed. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns with the attending veterinarian before the procedure is initiated. ©2021 Georgia Veterinary Associates. À•p|î„O×àX _______ I understand that incase of a post-op emergency or complication, or if my pet damages or removes the surgical • Withhold all food and treats after 9:00pm. Yes No. There is the possibility of complications, How fully your pet might respond or recover and how long it could take 4. We require a phone number(s) where you can be reached on surgery day so that if questions arise our staff is able to contact you. I consent that I am 18 years of age or older and am the owner or authorized agent responsible for the pet described below. I understand the nature and purpose of the operation. necessitate an extension of the procedure or surgery, or of different procedures or surgeries than those set forth above. Please read carefully all the enclosed information. Dental SUrgical COnsent Form. When you drop-off your pet for surgery the morning of their surgery, we will confirm with you the consent you have marked off on for each item below. These tests are similar to those your own physician would run if you were to undergo anesthesia. I agree to contact Operation:SNIP with any questions that arise following the medical procedure about my animal’s The physical examination and blood work done prior to any surgical procedure allows us to best minimize anesthetic and surgical risks and maximize patient safety. members or agents my consent to perform sterilization surgery upon the animal named above. If you have any questions, please feel free to call us. When you arrive to take your pet home, you will be escorted into an exam room and a veterinary technician will go over discharge information and instruction with you verbally and hand you a written copy. Surgical Anesthesia: Both local and general anesthesia involve risk. We require a phone number (s) where you can be reached on surgery day so that if questions arise our staff is able to contact you. … Yes No. I certify that the animal has had no food since 12:00 midnight the evening prior to surgery (except for puppies less than 4 months of age). We require the placement of an IV catheter and use of IV fluids during all general anesthetic procedures. I understand that during the performance of this procedure, ... Microsoft Word - Surgical Consent Form 2017.docx Created Date: I consent to any such additional procedure(s) and agree to take full responsibility, financial and otherwise, if the animal becomes ill. 3. If you have any questions regarding the risks of this procedure and expected outcome please feel free to discuss it with us prior to surgery. We use a combination of pre-anesthetic medications/injectable and/or inhalant anesthetics to achieve optimum levels of anesthesia that are safe for your pet. Post-Procedure. On your pet’s surgery day, we require you to review and sign a Surgery/Anesthesia Consent Form in which you acknowledge understanding of this surgical information packet. All Georgia Veterinary Associates' Hospitals are continuing to provide Curbside Care and Virtual Visits until further notice. **After 9:00 pm the night of surgery, refer to the following: If there are any questions or concerns directly related to the surgery during the recovery period, please call this office at 904.829.2737. BAH Anesthesia/Surgery Consent Form Page 2 Microchip In an effort to offer permanent identification and help assist in your pet’s safe return in the event he/she becomes lost, Brookstone Animal Hospital offers microchip implantation at the time of surgery. I have been advised as to the nature of the procedures or operations. Your pet has been scheduled for surgery in the near future. Not only does it provide a record of insulin administration, the form enhances communication when multiple family members are involved in the care of a diabetic pet. The day of your pet’s appointment you will be asked to sign a Medical Consent Form to authorize surgery and other medical procedures for your pet. This allows us to have quick, available access to the circulatory system (blood) in case of an unforeseen emergency. For most procedures, your pet is anesthetized and then intubated (insertion of a tube into the trachea or wind-pipe). Complete the form below or download the form to complete it at your convenience. Second, our doctors and technician will use a computerized monitor that records heart rate, pulse rate, oxygen levels, respiration rate, ECG; temperature. After surgery your pet is monitored in a recovery unit with warm blankets. As a member of the treatment team, you have been informed of your diagnosis, the planned procedure, the risks, benefits, and alternatives associated with the procedure, and any associated costs. If your pet is brought to the Clinic by another individual they will be asked to sign on your behalf. Pet Surgery Consent Form and Questionnaire Form – This is the variety of consent form intended to be signed by a pet owner for a pet or an animal who needs to undergo surgery and medical treatments. I hereby forever release and hold harmless Black Dog Veterinary Services and any authorized agents, staff, or representatives from any and all liability for euthanasia and disposal of said animal. • Water may be left down overnight but should be withheld after 7am the morning of surgery. I agree to waive any or all claims against Wellness Veterinary Clinic in the event of injury,complications, or death of my animal. Risks may include, but are not limited to, anesthetic death, infection and if applicable implant failure, delayed healing, and persistent lameness. Consent . Our clinic strongly believes in compassionate, quality, medical care for our patients. In our attempt to assist clients, we have assembled this packet to make surgery day as easy and stress-free as possible. Please understand that no surgical procedure is risk free. Pre-Surgery Instructions. First, a veterinary technician is with your pet continuously from beginning of anesthesia through recovery. authorization or consent from the owner or authorized representative. The purpose of this consent form is to inform you that there are potential risks and that you understand this before the procedure and consent to continue anyway. Medications. In addition to this letter, you will find that the following information has been enclosed: 3. Canine Surgery Consent Form - I hereby authorize treatment up to and including chest compressions, medications, and artificial respiration in the case of an unforeseen emergency. temporary or permanent and even death. • If you are currently administering any medications, vitamins and/or injections, withhold the morning doses unless otherwise instructed by the doctor. Procedure Consent Form Fill out this form in advance of dropping off your pet on surgery day to save time. Once the surgical procedure is complete and your pet is in stable condition in the recovery unit, the veterinarian will call you personally to discuss the procedure and will be able to give you an idea when your pet may be discharged. I am 18 years of age or older and the owner or authorized agent responsible for the animal(s) described below. We require that a Pre-Anesthetic Blood Profile be performed on all pets’ undergoing anesthesia to maximize patient safety. Surgical Consent Form. Any medical and/or surgical treatment alternatives for your pet 2. I, do hereby certify that I am the owner (or duly authorized agent for the owner) of the animal described above, that I do hereby give Mills Animal Hospital complete authority to perform the surgical and/or dental procedure. In addition, all dogs scheduled for surgical procedures must provide proof of heartworm testing and prevention. Sufficient details of this consent form and how they apply to your dog 3. Surgery Consent Statement: I have been advised as to the nature of the procedure(s) or operation(s) and the risk involved. Please make arrangements for your pet to be dropped off on the morning of scheduled surgery, and allow 10-15 minutes for a veterinary technician to meet with you to discuss your pet’s surgery and answer any questions/concerns you may have. All Rights Reserved. We consider brachycephalic dogs a high risk population. Surgery Consent Form - I understand that during the performance of the procedures or operations, unforeseen conditions may be revealed that necessitate an extension of the procedure or operation or different procedures or operations than those set-forth above. Please fill in the date of the procedure being performed. Surgery Consent Form We recommend that your cats be tested for FeLV/FIV prior to surgery. Remember, our team knows surgery can be an anxious time and we are always available to answer any and all questions concerning the upcoming procedure. Veterinary Surgical Consent Template has the pet information, owner details, surgery information, and authorization or consent that the medical staff requires the pet owner to … This essential testing helps alert our surgeon to the presence of dehydration, anemia, infection, diabetes and/or kidney or liver disease that could complicate the procedure. For procedures that require minimum sedation, an injectable anesthetic is given that produces a good plane of sedation with quick recovery. We hope surgery day will be a pleasant experience. Please be sure you talk with your doctor about the following: 1. My dog is currently on heartworm prevention: YES / NO I would like to have my dog tested for heartworm: YES / NO By signing this consent form, I agree that the following statements are true: I am the owner (or owner’s agent) of _____. Desensitization training. 4. We require a phone number (s) where you can be reached on surgery day so that if questions arise our staff is able to contact you. To decrease risk, preanesthetic labwork is available to be done same day before anesthesia for dogs … In addition, these tests may be useful if your pet’s health changes to develop faster, more accurate diagnoses and treatments. You are welcome to check on your pet’s status, however, we request that you allow plenty of time for your pet’s procedure to be done. All Paws Animal Hospital Surgical Authorization and Release Form this is a legally binding document, read before signing. On your pet’s surgery day, we require you to review and sign a Surgery/Anesthesia Consent Form in which you acknowledge understanding of this surgical information packet. _____ To my knowledge, this animal is in good health. {{{;Ž}ƒ#âtp¶8_\. Please make sure you are accessible all day at the number(s) you provide.
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