Orthopedic Informed Consent Form

Please enable JavaScript in your browser to complete this form.

Pet's Name:

Pet Parents First Name:

Last Name:

Please read and check each box to indicate your agreement with each statement.

I, the undersigned, owner or responsible party of the admitted patient, hereby authorize the veterinarians of Parkland Veterinary Clinic (and whomever they may designate as assistants) to administer such treatments as necessary, and to perform surgical procedures and additional procedures as are therapeutically and/or diagnostically necessary as indicated by findings during medical evaluation.

Statement Approval

I understand and accept that there are always inherent surgical and/or anesthetic complication risks, including but not limited to Hypothermia, Low or High blood pressure, Corneal Ulceration, Unexpected drug reactions, Tracheal Injury, Esophagitis, Blood Clot Formation, Lung Injury, Aspiration Pneumonia, and death of the patient.

statement. check following

The following options can help to reduce the risk associated with anesthesia and maximize patient safety. We highly recommend these measures for every patient having a surgical procedure.

Pre-anesthetic bloodwork: the risk of anesthesia complications is high in animals with health problems. We recommend pre-anesthetic bloodwork for every patient having a surgical procedure. This checks for subclinical disease (hidden problems) not apparent on physical examination. Based on this bloodwork, we can tailor your pet’s anesthetic, pain management and recovery protocols to her/his individual needs. The fee for pre-anesthetic bloodwork is: Pre-Anesthetic CBC: $71.00+ GST – Pre-Anesthetic CHEM: $109.50+GST

Please select one of the following statements below:

I authorize BOTH pre-anesthetic bloodwork
I do NOT authorize any pre-anesthetic bloodwork as it’s been completed at another veterinary clinic.

Intravenous Fluids Information:

Intravenous Fluids: Intravenous (IV) fluids are very important for all procedures that require general anesthesia. Administration of IV fluids helps your pet recover more quickly from anesthesia, maintains blood pressure, and increases circulation during anesthesia. It also allows rapid administration of drugs should an emergency arise and can save vital time in the rare event of an anesthetic complication. To place an IV catheter and fluids it is necessary to clip or shave hair from the site (forearm or back legs). In cases where further work is required and is of non-emergency nature (non-life threatening), every attempt will be made by the doctor/staff to contact the owner by phone to discuss the case. Please be aware that if you decline any needed procedures at this time, or we are unable to reach you within 5 minutes, your pet will need a second anesthesia at another time for those procedures to be performed.

Statement Approval

Once the case has been discussed and verbal consent has been obtained, I understand and accept the nature of the procedure(s) that the Doctor in his/her professional judgement deems necessary and desirable, and grant authority for the purpose of remedying conditions that are not known at this time, but which may become evident while the patient is in hospital. However, I understand that if efforts are unsuccessful to contact me on the phone numbers provided, no additional work will be performed and may have to be completed at a later date.

Statement Approval

I understand and accept that if my pet requires overnight hospitalization, there is no overnight staff on duty after the hospital closes, and that my pet will be attended to the following morning.

Resuscitation Wishes:

I authorize for immediate resuscitative efforts be made, and I am responsible for any additional costs incurred
I DO NOT wish for immediate resuscitation efforts to be made

If an unexpected cardiopulmonary arrest occurs during surgery, you will be contacted as soon as possible. However, prior consent is needed for resuscitative efforts (CPR) to be initiated before you can be reached. With the consent of this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will continue to be performed at the doctor’s discretion.

Statement Approval

I hereby certify that I have read and fully understand the above authorization for medical and/or surgical treatment. I am aware that Parkland Veterinary Clinic does not employ any board-certified surgeons and authorize the general certified veterinarians of this facility to perform the above surgical procedure on my pet. I also certify that the procedure has been explained to my satisfaction, and I have no further questions or concerns.

Statement Approval

I hereby certify that no guarantee or assurance has been made regarding the results that may be obtained. I acknowledge that any post-surgical or post-anesthetic complications may require additional veterinary care or medications. Further, I assume full financial responsibility for all charges incurred to this patient.

Please read and check the box of the following only if your pet is getting spayed or neutered.

I understand that there will be additional fees in surplus of the base surgical cost of spay/neuter, if my animal is:

Owner/Responsible Party of Admitted Animal Signature

0 Shares

Find Us

Clinic Hours

Our Location