Referral Surgery & Dental Consent Form

Today's Date*

Owner's Name*

First Last

Co-Owner's Name

First Last

If applicable

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Disclaimer

Your pet will be scheduled for a procedure that requires anesthesia, though very unlikely, anesthesia inherently carries some risk. Therefore, we would like to take this opportunity to explain why pre-anesthetic blood testing will be performed and why it is important to the health of your four legged family member. The anesthetic agent is removed from the body by the liver and kidneys, so it is important to know before anesthesia that these organs are functioning at 100%. Like you, our greatest concern is the well-being of your pet. Before putting him/her under anesthesia, a veterinarian will perform a full comprehensive physical examination to identify any existing medical conditions that could complicate the procedure and compromise the health of your pet. There is always the possibility that a physical exam alone will not identify all of your pet’s health problems. The pre-anesthetic blood profile (a combination of blood tests) is performed prior to anesthesia. This blood profile that we complete in our lab is similar to, and equally as important as those your own physician would run if you were to undergo anesthesia. Results will be immediately available before general anesthesia and/or surgery. The cost of this pre-anesthetic blood profile is included in your estimate. It is important to understand that a pre-anesthetic blood profile does not guarantee the absence of complications. It may, however, greatly reduce the risk of complications that could require medical treatment in the future. If your pet is geriatric or ill, we strongly recommend upgrading to a full comprehensive blood screening.

Bloodwork Consent*

Yes, I want to upgrade my pet’s blood work and have a full comprehensive blood screening at an additional cost of $194.00 (Includes all of the pre-anesthesia blood work, as well as, thyroid function, protein levels, calcium, phosphorus) ***Strongly recommended for patients over 8 years of age.
No, I would not like to upgrade my pet's blood work

ECG Safety Option for All Pets

We offer electrocardiogram (ECG) to all patients as part of the pre-surgical work-up. An ECG is a diagnostic tool used to screen patients for the presence of hidden heart disease and/or arrhythmias that can form at any age. ECG’s are conducted the morning of surgery and are evaluated by board-certified cardiologist prior to surgery. Anesthesia protocols are often based on the findings of these reports. ECG’s are optional, but highly recommended tools to ensure a favorable outcome for your pet’s procedure.

ECG Consent*

Yes, I want my pet to have a pre-anesthesia ECG at $114.50
No, I decline at this time for an ECG to be performed.

Should any unforeseen procedures be necessary and desirable in the veterinarian’s professional judgment, please check one of the following options:*

I prefer that you proceed with all necessary procedures.
I prefer to be called before any additional procedures, other than emergencies. If I cannot be reached, I DO authorize you to proceed with any procedures as deemed necessary by the doctor. The phone number I can be reached at is: (list below)
If I cannot be reached by phone, I DO NOT authorize any additional procedures.

Phone

List below the medication(s) that your pet is currently taking and when they were last given

PLEASE BRING THESE MEDICATIONS WITH YOU THE DAY OF SURGERY.

Please check below indicating that you acknowledge the following statements:

Our practice understands the importance of pain management and control for our patients. If indicated we will be administering additional pain relief medication, and there will be a corresponding charge on your bill.*

Yes, I have read the above statement and understand.

In almost all cases, a small area on the front leg will be shaved and an IV catheter will be placed for the surgical procedure. This allows our staff to administer medications and provide maintenance fluids while your pet is under anesthesia. Additionally, hair will be shaved at the surgery site (sometimes extensively) to assure sterility and the safety of your pet.*

Yes, I have read the above statement and understand.

Licking, chewing, and/or scratching at the surgical incision greatly increases the risk for surgical complications such as infection and/or dehiscence. If your pet is licking, chewing, and/or scratching at their incision while here they will be fit with an Elizabethan collar (or other similar device). Elizabethan collars are required with certain procedures such as orthopedic surgery. There will be a corresponding charge.*

Yes, I have read the above statement and understand.

In almost all cases, a small area on the front leg will be shaved and an IV catheter will be placed for the surgical procedure. This allows our staff to administer medications and provide maintenance fluids while your pet is under anesthesia. Additionally, hair will be shaved at the surgery site (sometimes extensively) to assure sterility and the safety of your pet.*

Yes, I have read the above statement and understand.

Authorization to Perform a Dental Cleaning and or Extractions

Dental disease may not reveal itself until a thorough exam under general anesthesia is performed. Dental radiographs are utilized to assess disease below the gum line during this exam. Every attempt will be made by the doctor to preserve your pet’s teeth, however in cases where extractions are required these are done with your pet’s health and best interest in mind. Common reasons for a simple and surgical extractions include broken teeth, abscessed roots, damaged sockets, cyst formation, and so on. In some cases, multiple extractions are necessary to ensure your pet’s comfort and health. Even in those cases, we will not exceed the formal estimate that you have received.

Dental Clean Consent*

Yes, I have read the above statement and understand.
My Pet is not here today for a dental procedure.

Authorization to Perform Surgery

I understand that there are risks associated with anesthesia the procedures set forth above. I am satisfied after speaking with the staff of Frey Pet Hospital that they will treat as they deem necessary for ’s health, safety, and well-being; however, I do understand that no guarantee of successful treatment can be made. I acknowledge that I have read and fully understand this Authorization for Medical Treatment, the reason why such medical treatment is considered necessary, as well as its advantages and possible complications, if any.

Authorization*

I have received an estimate for the procedure. (If you have not, please ask for one now!) I understand that payment is due at the time is discharged and that a deposit may be required for extensive medical or surgical procedures.

Digital Signature Adknowlegement*

I declare the above information is correct to the best of my knowledge, and I give procedure consent to the areas marked.

Consent*

I agree to the below consent policy.

I, the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the pet listed above. Surgery cases are assigned to staff veterinarians on a rotational basis, unless a request is made for a specific veterinarian. I do hereby give Dr. Steen, or his agents, and/or representatives, full and complete authority to administer such treatment as is necessary to perform the following procedure(s). *If you have not received a written estimate, and would like one, please ask now.

Pet Name*

Print Name*

Electronic Signature*

Date*

Emergency Phone Number*

Disclaimer

ECG Safety Option for All Pets

Please check below indicating that you acknowledge the following statements:

Authorization to Perform a Dental Cleaning and or Extractions

Authorization to Perform Surgery

Location

Hours of Operation