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info@familypethealth.com
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Day Admission with Surgical Consent
Please fill out this consent form electronically prior to your visit.
Please enable JavaScript in your browser to complete this form.
Date
Person Responsible for Care Decisions
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First
Last
Email
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Best number today to reach the person responsible for care decisions
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Pet's Name
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Is, or may, your pet pregnant?
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Yes
No
Reason for visit:
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We are so glad you have decided to entrust your pet to us. We follow the Fear Free approach for all of our patients.
Because you know your pet better than anyone, we need your help to make his or her visit Fear Free!
Please describe the items you are sending with your pet for the surgery.
What medications/supplements is your pet taking?
Any vomiting/diarrhea or coughing/sneezing? If so, please explain.
We want your pet to feel safe and secure in our care. If our veterinarians determine that your pet is concerned or worried and is unable to relax during the visit, they may review its medical record and consider prescribing dietary supplements or medication to help decrease fear and anxiety.
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I have read and understand.
I authorize the use of appropriate anesthesia and pain relief medication as needed before, during or after the procedure. I have been informed that there are risks associated with the use of any medication.
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I have read, understand, and authorize.
I have been informed that there are certain risks and complications associated with sedation, anesthesia, and/or any operation/procedure and that the risks/complications have been explained to me. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before the procedure is initiated.
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I have read and understand.
The nature of these operations or procedures has been explained to me and I understand what will be done. I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. I have been encouraged and given the opportunity to discuss any questions I may have regarding my pet's medical care and my questions have been answered to my satisfaction. I accept that my financial obligations remain regardless of the outcome.
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I have read and understand.
I understand that if at anytime during my pet's visit with Family Pet Health fleas are found, a Capstar pill will be administered for an additional $15.00. By signing below, I agree to the Capstar administration and understand that I am responsible for the fees.
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I have read and understand.
I understand that my pet must be current on all vaccinations and testing in order to be kept at Family Pet Health, by signing below, I agree to the necessary vaccinations and testing to make my pet comply to Family Pet Health standards.
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I have read and understand.
I understand that Family Pet Health is a teaching hospital and that my pet may be treated by a veterinary student under the supervision of a licensed veterinary professional. I will share any concerns about the teaching arrangement with the supervising veterinarian.
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I have read and understand.
In the event that your pet were to experience a cardiac or respiratory arrest (no longer have a heartbeat or stop breathing), our standard procedure would be to initiate Cardiopulmonary Resuscitation (CPR). Please note that costs of this can range from $250-$500 depending on the nature and duration of intervention. As a pet owner, you may prefer to not have resuscitation performed. In such cases, you have the option to elect a Do Not Resuscitate (DNR) order.
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Yes. If necessary, I wish to have CPR performed on my pet.
No, thank you. If my pet passes away, please do NOT resuscitate him/her.
By signing below I agree that I have had the opportunity to ask questions regarding what will be done to my pet during its visit. My questions have been answered and I assume all financial responsibility incurred during the visit.
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I have read and understand.
Surgical Consent
Brief description of procedure
An anesthetic will be given prior to your pet's surgical and/or dental procedure today. We want you to know that inherent risks exist, such as anesthetic complications, bleeding during and after the surgery, and pain and swelling at the surgical site. Fortunately these complications are very rare. Precautions are taken to keep these risks, some of which may be life threatening, to a minimum. In some cases, we require pre-anesthetic blood tests that give us a more complete picture of your pets overall health and ability to metabolize anesthesia.
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I have read and understand.
Pre-Anesthetic Blood Work: Cost $69.62 We strongly recommend a pre-anesthetic blood profile prior to any surgery or dental procedure. Although the blood profile does not totally eliminate risk, it greatly reduces the possibility of complications from liver or kidney dysfunction which can affect the ability of your pet to metabolize the anesthetic drugs. It also may serve to identify conditions that may require future treatment.
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I accept pre-anesthetic blood work: $69.62 (required if your pet is 5 years of age or older)
I decline pre-anesthetic blood work
(Please Note: This is required if your pet is 5 years of age or older)
MicroChip Implantation: Cost $40.00 Microchips are implanted below the skin at the base of the neck between the shoulder blades. The microchips we use are recognized internationally and can help to identify your pet if it is lost or stolen. The chip (once registered) will be connected to our clinic and also have your contact information associated with it. Anyone with a microchip scanner will be able to scan your pet and see who they belong to.
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Yes, I want to have my pet microchipped
No, I do NOT want my pet microchipped
My pet already has a microchip
Cerenia Injection: Cost $25-75 based upon pet's weight. Cerenia is an antiemetic used to prevent nausea/vomiting and encourage eating after anesthesia/surgical procedure. An exact estimate can be created based upon your pet's weight.
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Yes, I want to have my pet to receive a Cerenia injection.
No, I do NOT want my pet to receive a Cerenia injection.
I am utilizing a Cerenia tablet.
Complimentary Nail Trimming: Many pets experience high levels of stress when having their nails trimmed. As a courtesy to our clients, we offer this service free of charge while your pet is under anesthesia.
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Yes, I would like to have my pet's nails trimmed as a part of their procedure if possible.
No, I do not want my pet's nails trimmed as a part of their procedure unless deemed necessary to protect their safety or the safety of the medical team caring for them today.
For dental cleanings/surgery: In the course of the dental procedure, our treatment team may make the determination that additional teeth should be extracted that may not have been discussed as part of the care plan. Without prior authorization, our team will attempt to contact the person responsible for care decisions before proceeding with any extractions. If the team is unable to contact the person responsible for care decisions within 10 minutes, we will stop the dental procedure and bring the pet out from under anesthesia.
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I understand and pre-authorize extractions based upon the medical judgement of the team at Family Pet Health.
I understand and wish to be contacted before any medical action is taken with the understanding that if I can not be reached, the team from Family Pet Health will bring my pet out from anesthesia.
N/A as my pet is not scheduled for a dental procedure
I, the undersigned, 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 Family Pet Health complete authority to perform the surgical and/or dental procedure. I do hereby forever release the doctor, agents, servants, or representatives from any and all liability arising from said surgery on said animal.
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I have read, understand, and authorize.
Signature
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Clear Signature
I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. My signature above certifies that I am over eighteen years of age.
Submit
