Surgery Consent Form -

Surgical Procedure*

Pet's Name

Pet Parent's Name*

First Last

Best number to reach you at today?*

Secondary Phone Number

Last Meal Time*

Last Drink Time*

Other Medications/Concerns

Edmonton West Animal Hospital performs multiple anesthetic procedures each day. While we strive to get your pet home to you as soon as we can, extenuating unforeseen circumstances such as emergencies, urgent walk ins, and surgical complications or delays on other procedures can delay the completion of your pet's procedure. If your pet is scheduled for a day procedure, it will be completed that day, however, we cannot guarantee what time your pet will be ready. Please plan to leave your pet with us for most of the day, and you will be contacted when your pet is ready for pick up.

PLEASE READ AND INITIAL IN FRONT OF EACH APPLICABLE STATEMENT IN THE SPACE PROVIDED

I, the undersigned, owner or responsible party of the admitted patient, hereby authorize the veterinarians of the Edmonton West Animal Hospital & Spay/Neuter Centre (and whomever they may designate as assistants) to administer such treatments as necessary, and to perform surgical procedures and additional procedures as are therapeutically and/or diagnostically necessary as indicated by findings during medical evaluation. Since general anaesthesia or sedation is required in these surgical procedures, I understand and accept that there are always inherent surgical and/or anesthetic complication risks, including death of the patient.

The following options can help to reduce the risk associated with anaesthesia and maximize patient safety. We highly recommend these measures for every patient having a surgical procedure.

Pre-anaesthetic blood screen: the risk of anaesthesia complication is higher in animals with health problems. We recommend pre-anesthetic blood screen for every patient having a surgical procedure. This checks for subclinical disease (hidden problems) not apparent on physical examination. On the basis of this blood work we can tailor your pet's anesthetic, pain management and recovery protocols to her/his individual needs. The fee for pre-anesthetic blood screen is $120.00.

I confirm below that I authorize pre-anesthetic blood screen or that I don't authorize pre-anesthetic blood screen and accept the inherent associated risks

Please watch the "Pre Anesthetic Concerns" video (https://vimeo.com/102370458)*

I agree that I have watched the "Pre Anesthetic Concerns" video

Please select one of the following statements below:*

I authorize pre-anaesthetic blood screen
I don't authorize pre-anaesthetic blood screen and accept the inherent associated risks

Intravenous fluids (Drip): Intravenous (IV) fluids are very important for all procedures that require general anaesthesia. Administration of IV fluids helps your pet recover more quickly from anaesthesia, maintains blood pressure, and increases circulation during anaesthesia. It also allows rapid administration of drugs should an emergency arise and can save vital time in the rare event of an anaesthetic complication. To place an IV catheter and fluids it is necessary to clip or shave hair from the site (forearm or back legs). The fee for placing an intravenous catheter with fluids is $60.00.

I gree to confirm below that I authorize IV fluids or that I don't authorize IV fluids and accept the inherent associated risks

Please select one of the following statements below*

I authorize IV fluids
I don't authorize IV fluids and accept the inherent associated risks

**PLEASE READ THE FOLLOWING STATEMENT ONLY IF YOU DECLINED INTRAVENOUS FLUIDS:

Intravenous catheter: If you declined IV fluids, we STRONGLY recommend placement of an intravenous catheter. The intravenous catheter allows rapid administration of drugs should an emergency arise and can save vital time in the rare event of an anaesthetic complication.The fee for placing only an intravenous catheter without fluids is $30.00.

I confirm below whether I authorize placement of IV catheter or if I don't authorize placement of IV catheter and accept the inherent associated risks

Please select one of the following statements below*

I authorize placement of IV catheter
I don't authorize placement of IV catheter and accept the inherent associated risks

Additional non-emergency work consent*

In cases where further work is required and is of non-emergency nature (non-life threatening), every attempt will be made by the doctor/staff to contact the owner by phone to discuss the case. Please be aware that if you decline any needed procedures at this time, or, we are unable to reach you within 5 minutes, your pet would need a second anesthesia at another time in order for those procedures to be performed.

I understand that there will be additional fees in surplus of the base surgical cost of spay/neuter in certain circumstances:

If my pet is cryptorchid (absence of one or both testes from the scrotum), I understand and consent that there will be an additional cost of $150
If my pet is found to be in heat, I understand and consent that there will be an additional cost of $40
If my pet is found to be pregnant (up to 6 weeks), I understand and consent that there will be an additional cost of $80
If my pet is found to be pregnant (more than 6 weeks), I understand and consent that there will be an additional cost of $250
I understand and consent that if my pet is found to be pregnant or in heat, I will not be contacted during the procedure, and I authorize the doctors of Edmonton West Animal Hospital to proceed with the spay surgery. I assume full responsibility for the above fees associated with the patient.

Additional pain medication (Three days recommended - $7-$12 per day based on pet size)*

I authorize additional pain medications
I do not authorize additional pain medications

E-collar (cone) ($15-$40)*

I authorize use of a E-collar
I do not authorize use of a E-collar

Microchip ($45)*

I authorize microchipping
I do not authorize microchipping

Vaccines ($25 per vaccine)*

I authorize vaccinations
I do not authorize vaccinations

Vaccines - Please specify which vaccines are needed

Nail trim ($10)*

I authorize nail trims
I do not authorize nail trims

If you would like anything additional done at the time of surgery (e.g. baby teeth removal, hernia repair, dewormer, etc), please describe in the box below. Additional cost estimates, where applicable, will be provided to you before these services are carried out, and are at the discretion of the attending veterinarian.

If you wish to take your pet to a board certified veterinary surgeon, there is only one clinic in Edmonton, Guardian Veterinary Centre, where they work on a referral basis. Select "I would like to be referred" below and inform a staff member if you wish to be referred.

I will confirm below whether I would like to be referred to a board certified surgeon or whether I do not want to be referred

Board Certified Surgeon Request*

I would like to be referred to a board certified surgeon
I do not want to be referred

Consent*

I hereby certify that I have read and fully understand the above authorization for medical and/ or surgical treatment. I am aware that Edmonton West Animal Hospital does not employ any board certified surgeons, and authorize the general certified veterinarians of this facility to perform the above surgical procedure on my pet. I also certify that the procedure has been explained to my satisfaction, and that no guarantee or assurance has been made regarding the results that may be obtained. I acknowledge that any post surgical or post-anesthetic complications may require additional veterinary care or medications. Further, I assume full financial responsibility for all charges incurred to this patient.

Signature*

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Surgery Consent Form

Surgery Authorization

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