Patient Name:

Email *

Species:

Color:

Age:

Sex:

Procedure to be performed:

SPAY
NEUTER
OTHER

Other:

Patients who are not deemed to have a routine procedure could incure additional charges to the original quoted routine
procedure. ($25-300)

Any pet that is found to have fleas will be given a Capstar pill to kill all fleas on the patient. ($10-12)

A current Rabies vaccine is required on all patients ($20)

I am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consent.

I have been informed that there are certain risks and complications associated with any operation or procedure of this type. They have been explained to me as well. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures.

I authorize the use of appropriate anesthesia and pain relief medications as needed before or after the procedure. I have been informed that there are risks associated with the use of any medication.

I understand the clinic support personnel will be used as deemed necessary by the veterinarian. I am also aware that arising complications will not relieve my financial obligation for any and all costs incurred for procedures performed in the event complications may arise. I accept full financial responsibility for any and all services incurred and understand payment in full is due at the time of patient discharge.

In the event your pet’s condition becomes critical, please check one of the following options:

I authorize Vidalia Veterinary Clinic to perform emergency and/or lifesaving treatments and diagnostics on my pet. I agree that I will be responsible for any additional expenses regardless of the outcome. (CPR) - If you elect CPR your pet will receive an IV catheter REGARDLESS if emergency measures are needed. IV Catheter = $37
I do NOT authorize Vidalia Veterinary Clinic to perform emergency and/or lifesaving treatments and diagnostics on my pet. I understand and accept that my pet may die if no intervention is taken. (DNR)

Date

Optional Services: Please accept/decline the following services to be performed on your pet. The following optional services are NOT covered under ANY assistance programs, such as SOAPS and are at an additional cost to you. None of the following services are included in the quoted price for the procedure your pet is having. It is best medicine to elect the recommendations, but is not required.

Proceed with ovariohysterectomy (spay) if pregnant or in heat-This will result in termination of the pregnancy. If your feline is in heat additional charges will be added for the services as we are unable to tell until the surgery is started. Please bring to our attention if this is an issue and or concern for either circumstances.

I want to proceed if my pet is in heat or pregnant ($25-$85).
I do not want to proceed if my pet is in heat or pregnant and understand I will still be responsible for the charges incurred.

Proceed with castration(neuter) if cryptorchid- exploratory surgery to locate retained testicle(s).

I want to proceed if my pet is cryptorchid ($50-$300).
I do not want to proceed if my pet is cryptorchid and understand I will be still be charged for charges incurred.

K-Laser Treatment Post-Surgery- We recommend K-laser therapy post surgery to stimulate the body's natural ability to heal by using specific wavelengths of light (red and near-infrared) The effects of laser energy include improved healing time, pain reduction, increased circulation and decreased swelling. The K-laser can NOT be used on sites that may be cancerous or around the eyes.

I want K-Laser treatment post-surgery ($20)
I do not want K-Laser Treatment post-surgery for my pet.

Pre-Anesthetic Lab Work- Basic pre-anesthetic lab work including 14 Body Chemistry Function Parameters and a Complete Blood Cell count (CBC) is recommended on EVERY pet undergoing general anesthesia and mild sedation. This blood work is required for pets 7 years of age and older, as well as obese patients of any age. This lab work checks the pet’s basic kidney and liver function, blood glucose, protein levels, and white and red blood cell concentrations and can help minimize the risk of complications from medical conditions not evident during a physical examination. Based on the age/condition of the pet, additional or more involved lab work prior to anesthesia or sedation may be required. It is against our medical advice to decline this service.

I want pre-anesthetic blood work ($150).
I do not want pre-anesthetic blood work for my pet.

IV catheter and IV Fluids- The IV catheter allows for quick access to the vein in the event of an emergency. This is REQUIRED if you elect CPR for your pet. An IV catheter is required for pets 7 years of age and older, as well as obese patients of any age. IV fluid administration helps keep blood pressure at a normal level and helps protect the kidneys and liver during anesthesia. They can also help your pet wake up more quickly from anesthesia. It is against our medical advice to decline this service.

I want an IV catheter ($42).
I do not want an IV catheter for my pet.
I want IV fluids ($43).
I do not IV fluids for my pet.

Anti-Nausea Injection- We recommend an anti-nausea injection to prevent nausea and vomiting often resulting from narcotics and anesthesia. Studies have shown faster recovery and return to normal eating habits in pets receiving this injection prior to anesthesia.

I want the anti-nausea injection ($28.50-$75.50).
I do not want the anti-nausea injection for my pet.

Pain Medication- Pain medication in injectable form is given to EVERY pet undergoing a surgical and/or a potentially painful procedure at our clinic. Additional non-steroidal anti-inflammatory (NSAID) pain medication to go home is HIGHLY recommended post-operatively for pain management.

I want oral NSAID medication to take home for 3-7 days (starts at $20).
I do not want oral NSAID medication for my pet.

Sedative Medication- In order to keep your pet calmer during the recuperation period, we can send home a mild sedative.

I want oral sedatives to take home (starts at $20).
I do not want oral sedatives to take home for my pet.

E-Collar- Used to prevent licking and chewing at the incision site(s). It is against our medical advice to decline this service.

I want the use of an e-collar ($10-$30).
I do not want the use of an e-collar for my pet.

I understand as the owner of this patient, that I am fully responsible for any unforseen medical complications that may arise, as well as any additional cost associated with other recommended treatments.

Date

Anesthesia Sedation Consent Form

Anesthesia Sedation Consent Form

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