Surgery Consent Form

Anesthesia/Surgery Consent Form

Owner Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone Number (DAY OF PROCEDURE)

Patient's Name

First

Date of Birth

Species

Breed

Sex/Altered

Color

Referring Hospital

Attending Clinician

Surgical Procedure (MUST INCLUDE ANATOMIC LOCATION OR SIDE/LIMB)

Initial

I have read and understand the above statement. The potential complications relating to the procedure(s) have been discussed to my satisfaction.

I have been advised by my veterinarian listed above as to the nature of the procedure listed above, including potential complications and risks thereof. I authorize MEGAN M. SCHAIBLE, DVM, DACVS-SA, a representative of VET SURGICARE, PLLC (hereinafter "VSC"), to perform this procedure. I further understand that the above hospital (with the assistance of VSC personnel when needed) will be using medications, sedatives and/or anesthetics as needed to perform this procedure. I understand the above hospital will be responsible for providing and performing a preoperative/preanesthetic examination of my animal in addition to monitoring, premedication, induction, anesthesia, recovery and hospitalization of my animal. I understand no guarantee of warranty, expressed or implied has been made as to the outcome of the procedure(s).

Initial

I have read and understand the above statement, associated risks, party responsibility for anesthesia and my pet's exam, and lack of guarantee/warranty. Furthermore, I authorize Dr. Megan Schaible and VSC to perform the above procedure.

I understand that all forms of sedation, anesthesia and medications involve some risk, although every effort is made to make anesthesia as safe as possible. Although rare, severe unexpected complications can occur including but not limited to the possibility of: drug or allergic reactions, cardiac rhythm abnormalities, low blood pressure, vascular events or strokes, brain damage, cardiac or respiratory arrest, or, on very rare occasions, even death. Additionally, all surgical procedures involve some risks and complications can occur including but not limited to: infection, bleeding, blood clots with possible vascular migration, temporary or permanent (rare) nerve injury, loss of limb function, development or progression of osteoarthritis, failure/breakage, loosening of implants, or bone fractures. Additional testing, medications, and procedures may occur related to the above complications if they occur.

Initial

I have read and understand the above statement. The potential complications relating to the procedure(s) have been discussed with me to my satisfaction.

Should cardiopulmonary arrest occur I ______ elect to have CPR to be performed on the above described animal.

do not

Initial

Image and Educational Release

VSC may occasionally feature patients on social media (company website, Facebook, Instagram, YouTube, etc), in educational presentations or publications, or marketing products. I hereby irrevocably consent to the use of any images, videos, pet's name (owner name(s) will not be used), or the likeness of the above described animal by the VSC and its associates in any and all marketing or teaching materials.

Image and Educational Release Consent

Yes

Client Signature

Date

THIS CONSENT FORM MUST BE COMPLETE AND SIGNED OR SURGERY WILL NEED TO BE RESCHEDULED

Comments

This field is for validation purposes and should be left unchanged.