I, the undersigned owner, or agent of the pet identified above, authorize the staff of Winterville Animal Care to perform the previously discussed procedure.

I have been advised of the nature of the services and procedures to be performed, as well as the risks involved. While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow-up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is failure to comply with the aftercare instructions.

I understand that some risks always exist with anesthesia/sedation and surgical procedures. I understand that the attending veterinarian will make every effort to contact me regarding the treatment in the case of unforeseen emergencies.

Owner's Name *

First

Last

Email *

In the event of an emergency, I select the following resuscitation option: *

I give permission for life sustaining procedures- CPR (Cardiopulmonary Resuscitations)
I do not give permission for life sustaining procedures- DNR (Do Not Resuscitate)

The most common complication from anesthesia/sedation is nausea. To minimize this complication, we offer an injection prior to anesthesia/sedation to reduce nausea for 24 hours. This reduces your pets’ discomfort and will help your pet return to normal eating and drinking habits as soon as possible. *

I elect for my pet to receive a Cerenia (anti-nausea) injection.
I decline a Cerenia injection.

To minimize complications, all animals at Winterville Animal Care undergoing sedation/anesthesia are given physical examinations and receive anesthetic drugs tailored to them. Occasional problems can arise due to pre-existing conditions that are not evident during the pre-surgical examination. To avoid this, we recommend a pre-anesthetic blood panel to evaluate major organ function. *

I elect for my pet to have basic pre-anesthetic safety screening.
I elect for my pet to have extended pre-anesthetic screening.
I decline all bloodwork

Intravenous catheters are placed in all animals receiving general anesthesia. This price is included in the surgical price. IV catheters are critical if there is an emergency during the surgical procedure. IV catheters are also used to administer fluid therapy to maintain blood pressure and minimize dehydration during the surgical procedure. *

I elect for my pet to receive fluid therapy during the surgical procedure.
I decline fluid therapy.

A CO2 surgical laser can be used in place of a scalpel blade. Using the surgical laser will reduce bleeding, inflammation and pain. *

I elect for my pet to have this procedure performed with a surgical laser.
I elect to not use the surgical laser with this procedure.

To keep your pet comfortable an injection of pain medication is given after the procedure. This in combination with local blocks reduces your pets’ discomfort. The doctor will prescribe oral pain medication to keep your pet comfortable for the next few days. *

I understand that my pet will receive injectable and oral pain medication.

If your pet is scheduled for a Professional Dental Cleaning, your pet will be under general anesthesia for the procedure. Your pet's teeth will be scaled, polished, and evaluated for any abnormalities. In addition to the anesthetic related items mentioned above there are a few dental specific options provided below. Dental radiographs are included in your dental package. Dental radiographs are utilized to examine the tooth root that cannot be seen during an oral exam. This provides valuable information to assist the doctor's oral exam in determining which teeth may need extracting. Extractions are often needed to remove diseased, unstable, or infected teeth. These teeth are often painful for your pet. The chronic infection can lead to other systemic problems if left untreated. *

I give permission for extractions to be performed on my pet. I understand that extractions are charged per tooth.
I decline for my pet to have extractions performed.

If you give permission for extractions to be performed on your pet (question above), what cost amount should we not exceed? *

Would you like your pet to have a Plaque Prevention Gel applied after the cleaning?

Yes
No, thanks

The following are optional items that your pet can receive while in the office today:

A Microchip can be injected under the skin and will help identify your animal in the event he/she is lost or stolen. Free lifetime registration
Nail Trim
Anal Gland Expression
Ear Cleaning
Elizabethan Collar to prevent your pet from licking/chewing at the incision.

Signature *

Clear Signature

Emergency Contact Number 1

Emergency Contact Number 2

Surgical/Anesthetic Consent Form

Surgical/Anesthetic Consent Form

Questions?

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