Dog/Cat Non Routine Surgery Check In Pre-surgical Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Emergency Contact #*Date of Planned Surgery* Date Format: MM slash DD slash YYYY Patient's Name* First HistoryWhere does your pet spend most of his/her time?*IndoorOutdoorIndoor/Outdoor about equalHas your pet ever had a seizure?*NoYes, if so, please describeTell us about you're pet's Seizure*Date, time, nature of the eventHas your pet ever had a vaccine reaction?*NoYes, if so, please describeTell us about you're pet's vaccine reaction*Date, time, nature of the eventHas your pet ever had an allergic reaction?*NoYes, if so, please describeTell us about you're pet's allergic reaction*Date, time, nature of the eventHas your pet ever had surgery before?*NoYes, if so, please describeTell us about you're pet's surgery*Date, time, nature of the eventHas your pet been Spayed or Neutered?*Yes, NeuteredYes, SpayedNo, MaleNo, FemaleIs there any chance that your pet has been bred or is pregnant?*NoYesWhen was you're pet's heat?*Was food withheld after 10 pm the night before?*NoYesAre there any Medications that your pet is on routinely?*NoYesdo not include flea/tick or heartworm preventatives Please list your pet's medications & dose/time last time givenSurgical ProcedureWhich lump (s) are requested to be removed?Are there any additional procedures?*NoYes, if so, please describeAdditional Procedures requestedPre-surgical bloodwork is recommended on all patients going under anesthesia. Would you like bloodwork performed prior to surgery?*NoYes, is so, please let us know status [next question]Has bloodwork been done?*No, still needs done prior to surgeryYes, already doneWould you like a Home Again microchip inserted today?*NoYesPotential Complications of AnesthesiaAnesthesia 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.Consent Section 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 AgreeI 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 AgreeI Do Not AgreeI 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.
