Surgical Informed Consent Form

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Pet's Name:

Surgical Procedure:

Pet Parents First Name:

Last Name:

Best Phone Number to reach you today:

Secondary Phone Number:

Last Mealtime:

Current Medications/Supplements:

Other concerns:

Please read and check each box to indicate your agreement with each applicable statement. Parkland Veterinary Clinic performs multiple anesthetic procedures each day. While we strive to get your pet home to you as soon as we can, extenuating circumstances such as emergencies, urgent walks ins, and surgical complications or delays on other procedures can delay the completion of your pet’s procedure. If your pet is scheduled for a day procedure, it will be completed that day, however, we cannot guarantee what time your pet will be ready. Please plan to leave your pet with us for most of the day, and you will be contacted when your pet is ready to be picked up.

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.

The following options can help to reduce the risk associated with anesthesia and maximize patient safety.

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.

Please select one of the following statements below:

I authorize BOTH pre-anesthetic bloodwork
I authorize only pre-anesthetic CBC bloodwork
I authorize only pre-anesthetic CHEM bloodwork
I do NOT authorize any pre-anesthetic bloodwork and accept the inherent associated risks.

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).

Please select one of the following statements below:

I authorize IV fluids
I do NOT authorize IV fluids and accept the inherent associated risks.

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.

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: 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.

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

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:

Statement Approval

If my pet is found to be pregnant or in heat, I understand that I will not be contacted during the procedure, and I authorize the doctors of Parkland Veterinary Clinic to proceed with the spay surgery. I assume full responsibility for the fees associated with this patient.

Optional but recommended services:

Please select each option you would like to authorize.

Buster Collar (cone of shame)

I authorize
I do NOT authorize

Recovery Suit

I authorize
I do NOT authorize

before the where

Microchip

I authorize
I do NOT authorize

Tattoo

I authorize
I do NOT authorize

Vaccines

I authorize
I do NOT authorize

Nail Trim

I authorize
I do NOT authorize

If you would like anything additional done at the time of surgery (ex. Baby teeth removal, hernia repair, stenotic nares, dewormer etc.), please describe it in the box below. Additional cost estimates, where applicable, will be provided to you before these services are carried out, and are at the discretion of the veterinarian’s attention. Additional Procedures:

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.

Owner/Responsible Party of Admitted Animal Signature

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