Surgical Consent Form Are you a new client?(Required) Yes No Please complete our New Client Form before your visit.Owner's Name(Required) First Last Surgery being performed(Required) Best phone number to contact after procedure(Required)Email(Required) Today's Date(Required) MM slash DD slash YYYY Date of Procedure(Required) MM slash DD slash YYYY Pet's Name(Required) Pet's Gender(Required) Male Male (Neutered) Female Female (Spayed) When was your pet last in heat (last day of heat cycle) or pregnant?(Required) Pregnant or patients in heat will be subject to additional fees due to the increased complexity of surgery ($70).(Required) I have read and understand Is this a new pet?(Required) Yes No HiddenPet InfoSpecies(Required) Dog Cat Breed(Required) Color(Required) Age/Date of Birth(Required) Is your pet microchipped?(Required) Yes No Name of Previous Clinic Previous Clinic PhoneMay we request medical records? Yes No Any previous illnesses or surgeries?(Required) Yes No If yes, please explain(Required)Is your pet on any special diets or medications?(Required) Yes No If yes, please list the medication name and dosage and/or any special diets(Required)Did they receive medication this morning?(Required) Yes No What medication?(Required) HiddenSection BreakLike you, our greatest concern is the well-being of your pet. Prior to administering anesthesia to your pet, a full physical exam is performed. Included in the price of each surgery/procedure is: An intravenous catheter and fluid therapy Pain medication before the procedure and medication to go home Anesthesia monitoring Your pet will be undergoing general anesthesia plus a surgical procedure today. In order to recognize any underlying abnormalities your pet may have, we highly recommend having a pre-surgical blood profile run on your animal. This consists of a CBC, which will check blood cells and chemistry which will also check blood glucose, kidney, and liver enzymes. These blood tests will help us to assess the health status of your pet more completely and determine if there are any additional precautions we need to take before surgery. We require a blood profile for animals older than seven years.(Required) I have read and understand Cardiac Circulatory Pulmonary Resuscitation: I understand that risks and potential complications exist with anesthesia surgery and do not hold Blue Diamond Animal Hospital liable for those risks. The attending veterinarian will perform any necessary emergency care and I agree to assume all financial responsibility associated with my decision.(Required) I authorize the attending veterinarian to perform CPR I DO NOT authorize the attending veterinarian to perform CPR Is your pet current on their vaccines?(Required) Yes No My pet(s) need vaccines and I will cover the cost for the vaccines (Required for admission)Please select the vaccines your dog needs:(Required) DHA2P Parvo Bordetella Rabies Fecal Corona Biv Influenza Please select the vaccines your cat needs:(Required) FVRCP FeLV Rabies Fecal Has your pet ever had any vaccine reactions?(Required) Yes No If yes, please explain(Required)Has your pet ever had a seizure?(Required) Yes No Any coughing, vomiting, diarrhea?(Required) Yes No Any illnesses in the past 30 days?(Required) Yes No If yes, please explain(Required) Is your pet on any medication?(Required) Yes No Please list the medications your pet is currently taking (including name and dosage)(Required)If yes, did they receive medication this morning?(Required) Yes No Recommended/Optional Services (Additional Cost)Pre-surgical blood testing is recommended to help reduce the risks involved with anesthesia. This test checks the internal status of your pet, including liver and kidney function (these are the main organs that metabolize anesthesia, complete blood count, and blood glucose level. Please select an option below if you'd like to add pre-surgical blood testing.(Required) Pre-anesthetic panel with CBC (recommended for pets under 7 years) - $107 Comprehensive chemistry panel with CBC (required for pets over 7 years) - $154 Decline Recommended for all pets 7 years or older. - Required for those pets with a heart murmur prior to any anesthetic procedure. An ECG evaluates the heart's rhythm, and may aid in the diagnosis of a potential issue with the heart.(Required) Accept - $75 Decline Many pets experience vomiting following the administration of some anesthetic drugs. Cerenia can help prevent vomiting on the day of surgery, as well as help them return to normal feeding sooner.(Required) Accept - $64 Decline Recommended to aid in pain relief and healing. An opioid injection will be administered after the surgical procedure is done, and an additional oral pain medication will be sent home with you.(Required) Accept - $60-90 Decline Post-op sedatives: It is important for your pet to relax during the recovery period after surgery. We recommend sedatives for high energy pets since they do not understand the nature of their procedure. Prices vary by weight of pet.(Required) Accept - $7-50 Decline Laser Therapy promotes faster healing of any incision site. We highly recommended post surgery laser therapy as it helps reduce healing time as well as time spent in an E-collar. If Cancer is suspected, laser therapy is not advisable.(Required) Accept - $15 Decline Deep Ear Cleaning: It can be hard to clear debris in our pets ears when they are awake. We offer this service to do an in depth cleaning while they are under anesthesia.(Required) Accept - $48 Decline Nail Trim(Required) Accept - $15 Decline Dremel(Required) Accept - $31 Decline Anal Gland Expression(Required) Accept - $15 Decline Microchip Implantation (Includes registration)(Required) Accept - $50 Decline CPR - Your pet may require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency medications, or other interventions. If I request such emergency procedures, I agree to be held responsible for veterinary services provided to my pet while staff members pursue treatment and try to reach me for further directions. Regardless of my pet’s recovery or survival, I agree to pay CPR fees in addition to other fees already identified by the practice and agreed upon by me. By declining CPR, in the unlikely event my pet becomes unresponsive during anesthesia, I consent to allow my pet to pass away without intervention.(Required) I authorize CPR I do not authorize CPR As the owner or agent of the above animal, 18 years of age or older, I hereby give my consent to Blue Diamond Animal Hospital to perform a surgical procedure on my pet.(Required) I consent I, the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above and have the authority to execute this consent. I understand that during the performance of the procedure, an unforeseen situation may arise that necessitates an extension or variance in the procedure set above. I hereby authorize Blue Diamond Animal Hospital to use reasonable care and judgment in performing the procedure. I have been advised as to the nature of the procedures and the risks involved in performing general anesthesia on the above-described animal. I realize that results cannot be guaranteed. I understand that all pets presented to Blue Diamond Animal Hospital for a procedure must be current on vaccinations.(Required) I have read and understand this authorization and consent. I further understand that I assume financial responsibility for all services rendered. Digital Signature(Required) Date(Required) MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.
