Canine Neuter Surgery Check In Form – Butler Veterinary Associates and Emergency Center

Canine Neuter Surgery Check In

Pre-surgical

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Emergency Contact #*
Secondary Phone
Date of Planned Surgery*
MM slash DD slash YYYY
Patient's Name*
First
History
Where does your pet spend most of his/her time?*
- Indoor
- Outdoor
- Indoor/Outdoor about equal
Has your pet ever had a seizure?*
- No
- Yes, if so, please describe
Tell us about you're pet's Seizure*

Date, time, nature of the event
Has your pet ever had a vaccine reaction?*
- No
- Yes, if so, please describe
Tell us about you're pet's vaccine reaction*

Date, time, nature of the event
Has your pet ever had an allergic reaction?*
- No
- Yes, if so, please describe
Tell us about you're pet's allergic reaction*

Date, time, nature of the event
Has your pet ever had surgery before?*
- No
- Yes, if so, please describe
Tell us about you're pet's surgery*

Date, time, nature of the event
Was food withheld after 10 pm the night before?*
- No
- Yes
Surgical Procedure
Does your pet have any baby teeth that need extracted?*
- No
- Yes
Does your pet have any hernias that need repaired?*
- No
- Yes
Does your pet have any dewclaws that you want removed?*
- No
- Yes
Are there any additional procedures?*
- No
- Yes, if so, please describe
Additional Procedures requested
Would you like a Home Again microchip inserted today?*
- No
- Yes
Pre-surgical bloodwork is recommended on all patients going under anesthesia. Would you like bloodwork performed prior to surgery?*
- No
- Yes, is so, please let us know status [next question]
Has bloodwork been done?*
- No, still needs done prior to surgery
- Yes, already done
Potential Complications of Anesthesia

Potential Complications of Anesthesia
Anesthesia is a vital part of your pet’s care, but also comes with risks including blindness, deafness, brain damage, aspiration pneumonia and other potential problems (i.e. organ damage and death). Underlying conditions (kidney/liver disease, intestinal blockage, liver disease, trauma and internal bleeding, etc.) can increase the risks, but we closely monitor blood pressure, heart rate and respiratory rate and intervene if necessary to try to prevent any complications.

The following are rare potential complications that can arise with neutering your dog or cat.
Bleeding resulting in Scrotal bruising/Scrotal hematoma
Although we check for bleeding in surgery multiple times, a ligature can slip or a small vessel can start bleeding again when your pet’s blood pressure increases after surgery. This can result in bruising around the incision/scrotum or a blood clot in the scrotum (hematoma). Bleeding during the neutering procedure is more common in larger and/or older dogs.

Incisional Infection/Dehiscence
An incision is made through the skin and fat layers underneath to remove the testicles. This incision is closed with internal sutures (+/- external sutures). Excessive activity or licking at the incision can cause the incision to become infected and affect the integrity of the sutures resulting in opening of the incision. An additional surgery may be necessary to correct an infected incision or dehiscence.

Cranial Cruciate Ligament Rupture
Neutering of large breed dogs in particular at a young age causes delayed closure of the physis or growth plates resulting in longer bones and steeper angles within the joints; consequently, a higher number of cranial cruciate ligament ruptures are seen.

Eunuchoid syndrome (Decreased male characteristics)
Eunuchoid syndrome is having the characteristics of a castrated male where the secondary sex characteristics do not develop. This occurs when male animals are neutered at a younger age. These vary with breed but example include large head and body size, and decreased penile development.

Consent

I, the undersigned owner or agent of the owner of the pet identified above, certify that I am eighteen years of age or over and authorize the veterinarian(s) at this practice 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. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:

The reasonable medical and/or surgical treatment options for my pet.
Sufficient details of the procedures to understand what will be performed.
How fully my pet will recover and how long it will take.
The most common and serious complications.
The length and type of the follow-up care and home restraint required.
The estimate of the fees for all services.

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. I also understand that my pet’s medical condition may change for better or worse and the attending veterinarian(s) may add or change treatments to fit the needs of my pet’s care as long as it falls within the guidelines of the estimate that was provided to me.

I assume financial responsibility for the services rendered and provide payment via cash, credit card (not American Express), or check at the time my pet is discharged from the hospital. Should unexpected life-saving emergency care be required I elect one of the following: SEE ELECTIONS 1 & 2

Election #1 [Resuscitation]*

I Agree
I Do Not Agree [DNR choice will appear)

Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency drugs, or other heroic interventions, I request the veterinarian(s) at this hospital pursue such medical care. Having requested such emergency procedures, I agree to be held responsible for a minimum resuscitation fee of $160 to pay for the services performed while staff members pursue treatment and try to reach me for further directions. Regardless of my pet’s survival, I agree to pay this fee in addition to the other fees already identified by the practice and agreed upon by me.

Election #2 [DNR]*

I Agree
I Do Not Agree

I elect NOT to have the medical team pursue any lifesaving procedures. No person shall attempt to resuscitate my pet should my pet’s heart stop and or breathing stop. DO NOT RESUSCITATE (DNR). Instead, I request that the attending veterinarian assist my pet in dying in a peaceful manner

Signature of Owner or Agent*

Must be 18 years of age; In the event my pet is hospitalized beyond the first day at this facility, I understand that veterinary care during nighttime hours is provided at the discretion of the attending veterinarian, who is not present at the facility from midnight to 8 am. I am aware that there are other emergency facilities that have a veterinarian present at all times and have the option to transfer to one of these facilities. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made. I have read and understand the nature of the above procedures and give my consent to proceed.

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Canine Neuter Surgery Check In

History

Surgical Procedure

Potential Complications of Anesthesia

Consent