Healthy Start Spay/Neuter Anesthesia Consent Form Please fill out this form to help us prepare for your pet’s procedure. Client Name(Required) First Last Primary Phone Number(Required)Email(Required) Pet's Name(Required) Today's Procedure (check all that apply)(Required) Spay Neuter Gastropexy Stem Cell Harvest Biopsy Other If other, please specify(Required) Has your pet had any food past midnight last night? Please note, vomiting during and after surgery is very common and if they aspirate food/water they can have severe anesthesia complications, including death.(Required) Yes No Is your pet taking any medication?(Required) Yes No Name all medications your pet is currently on. Example: Vetprofen 25mg, 1 tablet every 12 hours(Required) Pre-Anesthetic Bloodwork (Recommended within 60 days of the procedure) Anesthetic episodes carry an inherent risk. Undoubtedly the importance of the procedure outweighs the potential for complications. Pre-anesthetic bloodwork will help minimize the risks during anesthesia and surgery. By testing blood chemistries and hematology values, we can better evaluate the status of your pet's major organ systems. Bloodwork is not included in the Healthy Start package. (Required) Anesthetic episodes carry an inherent risk. Undoubtedly the importance of the procedure outweighs the potential for complications. Pre-anesthetic bloodwork will help minimize the risks during anesthesia and surgery. By testing blood chemistries and hematology values, we can better evaluate the status of your pet's major organ systems. Bloodwork is not included in the Healthy Start package.(Required) Yes, I want pre-anesthetic bloodwork, and I accept this additional cost. Bloodwork already completed within 60 days. No, I decline pre-anesthetic bloodwork for my pet's surgery against medical advice. AGAINST MEDICAL ADVICE WAIVER: I understand that the bloodwork is necessary to assess my pet's blood clotting capability, and internal organ function, and to rule out any abnormalities such as liver shunts or anemia. Without pre-anesthesia bloodwork, it is not possible to determine if my pet has any of these underlying issues. I understand that certain breeds carry a much higher risk of congenital abnormalities that could lead to complications or death with anesthesia without the information provided by the pre-anesthesia bloodwork. Examples: Doberman Pinscher- Von Willebrand's Disease, Yorkshire Terrier - Portosystemic Shunt, All Purebred cats- blood clotting abnormality. I understand that the VMC doctors have the right to decline to perform a given anesthetic procedure if bloodwork is declined and against medical advice waiver is initialed. Initial to confirm your decline of pre-anesthetic bloodwork(Required) IV FluidsIntravenous catheter placement allows for IV fluid administration during and after surgery to maintain optimal blood pressure. It also allows for the immediate administration of IV emergency drugs should an anesthetic complication arise. Required for any age patient undergoing anesthesia and is included in the Healthy Start package. Anti-Nausea and Pain Medications General anesthesia may cause some pets to feel nauseous after surgery. Your pet will receive a 24-hour dose of an anti-emetic prior to surgery to help with this. Oral pain medications help to manage pain and inflammation to keep your pet comfortable during the initial recovery period. The surgery team will administer the first dose, and you'll receive 3-5 days' worth of pain meds to go home. These medications are included in the Healthy Start package. (Required) BiopsyIf a biopsy is being performed, then sending the sample to the lab for histopathology testing will provide important clinical information regarding your pet's health to determine if additional treatment is needed. (Note: This may already be included in your treatment plan.)(Required) Yes, I consent to the biopsy and the associated lab fee. No, I decline the biopsy. Optional Services That Can Be Performed While Pet SedatedMicrochip Permanent Identification ($85)(Required) Yes, I consent to the placement of a microchip under my pet's skin. No, I decline the placement of a microchip. My pet is already microchipped. Nail Trim ($25)(Required) Yes No Ear Cleaning ($25)(Required) Yes No Baby Teeth Removal ($45 per tooth)(Required) Yes No Health Concern Exam ($71) (Required) Your pet will receive a complimentary exam to assess vitals as well as cardiac and respiratory function before anesthesia. If you would like a separate health concern addressed there's an added examination fee and the doctor will speak to you regarding the exam findings. (Required) Health Concern Exam ($71)(Required) No, I have no health concerns that I would like examined on my pet Yes, I would like a separate health concern to be addressed and accept the additional cost. Please describe your concern(Required) Additional Services/Products: (vaccines, professional services, medication/preventative refills, etc.) E-Collar An e-collar (Elizabethan collar) is recommended for all procedures that involve an incision. It is critical to prevent self-trauma to the incision, which will delay healing and or lead to incision correction surgery. An e-collar has been included with your estimate for surgery. Some owners may prefer an e-collar that fits against the neck (similar to a human neck brace). Please speak to VMC staff if you wish to choose a different e-collar. If you decline an e-collar for your pet's recovery, it is against medical advice, and incision repairs are 100% client financial responsibility. An e-collar (Elizabethan collar) is recommended for all procedures that involve an incision. It is critical to prevent self-trauma to the incision, which will delay healing and or lead to incision correction surgery. An e-collar has been included with your estimate for surgery. Some owners may prefer an e-collar that fits against the neck (similar to a human neck brace). Please speak to VMC staff if you wish to choose a different e-collar. If you decline an e-collar for your pet's recovery, it is against medical advice, and incision repairs are 100% client financial responsibility.(Required) Yes, I would like an e-collar and I understand the importance of it for my pet's recovery. I decline an e-collar for my pet's recovery and I understand the above risks and responsibilities. I already have an e-collar for my pet. If you already have an e-collar, please bring it with you when you drop your pet off the morning of their procedure. It is very important for us to ensure that the size and fit are appropriate. Chill Pills (Dogs Only) Restricted activity is required for proper healing for 7-10 days. This can be difficult for our young and/or active/energetic canine patients. We have an oral medication that acts as a "chill pill" and helps your pet calmly handle the restricted activity. This can prevent incision complications which may incur additional charges and is very safe for dogs. Our veterinarians will evaluate each pet to ensure this is a safe, suitable option. Restricted activity is required for proper healing for 7-10 days. This can be difficult for our young and/or active/energetic canine patients. We have an oral medication that acts as a "chill pill" and helps your pet calmly handle the restricted activity. This can prevent incision complications which may incur additional charges and is very safe for dogs. Our veterinarians will evaluate each pet to ensure this is a safe, suitable option.(Required) No, my pet does not require Chill Pills. Yes, Chill Pills will assist my pet with the recommended activity restriction. I do not have a dog. Anesthesia RiskI, the undersigned owner or agent of the pet identified above, authorize the staff of Veterinary Medical Center of Fort Mill to perform the above procedure(s). I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. In the event that life-saving treatments are needed:(Required) I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. In the event that life saving treatments are needed:(Required) I elect to proceed with life-saving treatments. I DO NOT elect to proceed with life-saving treatments. Please initial to authorize your selection for life-saving treatment(Required) While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow-up radiographs, re-check physical exams, and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have read and fully understand the terms and conditions set forth above.Phone number at which owner can be reached before/after procedure(Required)Alternate phone number at which owner can be reached before/after procedureSignature(Required) Reset signature Signature locked. Reset to sign again Date(Required) MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
