Veterinary Surgery Consent Form

VETERINARY SURGERY CONSENT FORM

DOCUMENT INFORMATION

PRACTICE INFORMATION

[VETERINARY PRACTICE NAME]
- Address: [ADDRESS]
- Phone: [PHONE]
- Emergency Phone: [EMERGENCY PHONE]
- Fax: [FAX]

SECTION 1: PATIENT AND OWNER INFORMATION

1.1 Client (Pet Owner) Information

Best number to reach you on surgery day: [PHONE]

1.2 Patient Information

1.3 Emergency Contact

If you cannot be reached on the day of surgery:

• Name: [NAME]
• Relationship: [RELATIONSHIP]
• Phone: [PHONE]
• Authorized to make medical decisions: ☐ Yes ☐ No
• Authorized to approve expenses up to: $[AMOUNT]

SECTION 2: SURGICAL PROCEDURE

2.1 Procedure(s) to be Performed

Primary Surgical Procedure:

☐ Spay (Ovariohysterectomy)
☐ Neuter (Castration)
☐ Dental Cleaning and Extractions
☐ Mass/Tumor Removal - Location: [LOCATION]
☐ Laceration Repair
☐ Abdominal Exploratory
☐ Foreign Body Removal
☐ Cystotomy (Bladder Surgery)
☐ Gastropexy
☐ Cruciate Ligament Repair
☐ Fracture Repair
☐ Amputation - Limb: [SPECIFY]
☐ Eye Surgery: [SPECIFY]
☐ Ear Surgery: [SPECIFY]
☐ Other: [DESCRIBE PROCEDURE]

Additional Procedures (if applicable):

☐ Dental cleaning during anesthesia
☐ Microchip implantation
☐ Nail trim
☐ Ear cleaning
☐ Anal gland expression
☐ Other: [SPECIFY]

2.2 Reason for Surgery

[DESCRIBE DIAGNOSIS AND REASON FOR SURGICAL INTERVENTION]

2.3 Surgeon

Primary Surgeon: [VETERINARIAN NAME], DVM
License Number: [LICENSE NUMBER]

☐ Board-certified veterinary surgeon
☐ General practice veterinarian

SECTION 3: PRE-OPERATIVE REQUIREMENTS

3.1 Pre-Operative Testing

Pre-Anesthetic Blood Work:

☐ REQUIRED - Pre-anesthetic blood work is required for this procedure
- Basic panel (CBC, Chemistry) - $[AMOUNT]
- Comprehensive panel - $[AMOUNT]

☐ RECOMMENDED - Pre-anesthetic blood work is recommended
☐ I ACCEPT pre-anesthetic blood work - $[AMOUNT]
☐ I DECLINE pre-anesthetic blood work (I understand the risks)

Decline Initials: _______ Date: _______

☐ Blood work completed on: [DATE] - Results: ☐ Normal ☐ Abnormal (see notes)

Other Pre-Operative Tests:

☐ Chest X-rays - $[AMOUNT]
☐ ECG/EKG - $[AMOUNT]
☐ Additional testing: [SPECIFY] - $[AMOUNT]

3.2 Fasting Instructions

☐ I confirm my pet has been fasted as instructed:
- No food after: [TIME] on [DATE]
- Water restricted after: [TIME] on [DATE]

☐ Pet was NOT properly fasted - Surgery may need to be rescheduled

3.3 Current Medications

List all medications your pet is currently taking:

3.4 Known Allergies or Adverse Reactions

☐ No known allergies or adverse reactions
☐ Known allergies/reactions: [LIST WITH DETAILS]

3.5 Previous Anesthesia History

☐ No previous anesthesia
☐ Previous anesthesia with no complications
☐ Previous anesthesia complications: [DESCRIBE]

SECTION 4: ANESTHESIA CONSENT

4.1 Anesthesia Authorization

☐ I authorize the administration of anesthesia to my pet for the surgical procedure(s) described above

4.2 Understanding of Anesthesia Risks

I understand that anesthesia carries inherent risks, including but not limited to:

☐ Adverse reaction to anesthetic drugs
☐ Cardiovascular complications (irregular heartbeat, low blood pressure, cardiac arrest)
☐ Respiratory complications (difficulty breathing, aspiration)
☐ Hypothermia (low body temperature)
☐ Prolonged recovery from anesthesia
☐ Rare severe complications including death

4.3 Anesthesia Risk Factors

Risk factors that may increase anesthesia risk (check if applicable):

☐ Advanced age (senior pet)
☐ Very young (pediatric)
☐ Heart disease or murmur
☐ Respiratory disease
☐ Kidney disease
☐ Liver disease
☐ Diabetes
☐ Obesity
☐ Brachycephalic breed (flat-faced)
☐ Other health conditions: [SPECIFY]

4.4 Anesthesia Monitoring

I understand that during anesthesia, my pet will be monitored using:

☐ Continuous pulse oximetry
☐ Blood pressure monitoring
☐ ECG/Heart monitoring
☐ Temperature monitoring
☐ Capnography (CO2 monitoring)
☐ Dedicated anesthesia technician monitoring

4.5 IV Catheter and Fluids

☐ INCLUDED - IV catheter and fluids are included in the surgical package
☐ RECOMMENDED - IV catheter and fluids are strongly recommended
☐ I ACCEPT IV catheter and fluids - $[AMOUNT]
☐ I DECLINE IV catheter and fluids (I understand this increases anesthesia risk)

Decline Initials: _______ Date: _______

SECTION 5: SURGICAL RISKS AND INFORMED CONSENT

5.1 General Surgical Risks

I understand that all surgical procedures carry risks, including but not limited to:

☐ Bleeding (hemorrhage)
☐ Infection
☐ Wound complications (dehiscence, seroma, hematoma)
☐ Swelling and bruising
☐ Pain and discomfort
☐ Reaction to sutures or implants
☐ Nerve damage
☐ Need for additional surgery
☐ Scarring
☐ In rare cases, death

5.2 Procedure-Specific Risks

The following risks specific to [PROCEDURE NAME] have been explained to me:

[LIST PROCEDURE-SPECIFIC RISKS]

• Risk 1: [DESCRIBE]
• Risk 2: [DESCRIBE]
• Risk 3: [DESCRIBE]

5.3 Spay/Neuter Specific Risks

(Complete if applicable)

☐ Scrotal swelling/bruising (neuter)
☐ Ovarian remnant syndrome (spay)
☐ Urinary incontinence (rare, more common in large breed females)
☐ Potential behavior changes
☐ Weight gain tendency post-surgery

5.4 Dental Surgery Specific Risks

(Complete if applicable)

☐ Tooth fracture during extraction
☐ Jaw fracture (rare, more common in small breeds with periodontal disease)
☐ Oral-nasal fistula
☐ Need for additional extractions beyond estimate

Dental Authorization:
☐ I authorize extraction of teeth as medically necessary
☐ Contact me before extracting more than [NUMBER] teeth
☐ Contact me before exceeding $[AMOUNT] in dental procedures

5.5 Benefits of Procedure

The potential benefits of this procedure include:

[LIST EXPECTED BENEFITS]

5.6 Alternative Treatment Options

The following alternatives to surgery have been discussed:

☐ Medical management: [DESCRIBE]
☐ Watchful waiting/monitoring
☐ Palliative care
☐ No treatment (risks explained)
☐ Other: [DESCRIBE]

☐ I understand the alternatives and have chosen to proceed with surgery

5.7 No Guarantee

☐ I understand that no guarantee of successful outcome can be made
☐ I understand that complications may occur despite proper care
☐ I understand that additional treatment or surgery may be required

SECTION 6: INTRAOPERATIVE AUTHORIZATIONS

6.1 Unexpected Findings

If unexpected conditions are discovered during surgery, I authorize the veterinarian to:

☐ Proceed with medically appropriate treatment
☐ Contact me before proceeding with any additional procedures
☐ Use best medical judgment if I cannot be reached

Phone number to reach me during surgery: [PHONE]

6.2 Additional Procedures During Anesthesia

While under anesthesia, I authorize the following additional procedures:

☐ Microchip implantation - $[AMOUNT]
☐ Dental cleaning - $[AMOUNT]
☐ Nail trim - $[AMOUNT] or ☐ Complimentary
☐ Ear cleaning - $[AMOUNT] or ☐ Complimentary
☐ Removal of additional masses if found - Up to $[AMOUNT]
☐ Other: [SPECIFY] - $[AMOUNT]

6.3 Tissue/Biopsy

☐ Submit tissue for biopsy/histopathology - $[AMOUNT]
☐ Do NOT submit tissue for biopsy
☐ Contact me to discuss biopsy if abnormalities are found

6.4 Emergency Intervention

In the event of a life-threatening emergency during surgery:

☐ Perform all life-saving measures regardless of cost
☐ Perform life-saving measures up to $[AMOUNT]
☐ Do Not Resuscitate (DNR) if cardiac/respiratory arrest occurs

Owner Initials: _______ Date: _______

SECTION 7: POST-OPERATIVE CARE

7.1 Hospitalization

☐ Outpatient procedure - Same day discharge expected
☐ Overnight hospitalization recommended/required
- Estimated nights: [NUMBER]
- Estimated cost per night: $[AMOUNT]

7.2 Pain Management

☐ I authorize appropriate pain management for my pet
☐ Pain medication will be sent home for post-operative comfort
☐ I understand pain management is essential for proper healing

Pain Management Plan:
☐ Injectable pain medication at time of surgery
☐ Oral pain medication to continue at home for [NUMBER] days
☐ Additional pain management: [SPECIFY]

7.3 Post-Operative Instructions

☐ I understand I will receive detailed written post-operative instructions
☐ I understand I must follow all post-operative care instructions for proper healing
☐ I understand activity restriction is required for [NUMBER] days/weeks

7.4 E-Collar (Cone)

☐ E-collar IS required - Pet must wear to prevent licking/chewing incision
☐ E-collar recommended

☐ E-collar included in surgical package
☐ E-collar additional cost: $[AMOUNT]

7.5 Follow-Up Care

☐ Suture/staple removal appointment needed in [NUMBER] days
☐ Recheck appointment scheduled for: [DATE]
☐ I understand follow-up appointments are essential

SECTION 8: FINANCIAL AGREEMENT

8.1 Surgical Estimate

Estimate of Charges:

☐ I have received and understand the estimate
☐ I understand actual charges may vary and could exceed estimate

8.2 Deposit and Payment

☐ Deposit required: $[AMOUNT] - Due: ☐ Today ☐ At drop-off
☐ Balance due at time of discharge
☐ Payment plan available: ☐ Yes ☐ No

Payment Methods Accepted:
☐ Cash ☐ Check ☐ Credit Card ☐ CareCredit ☐ Scratchpay ☐ [OTHER]

8.3 Financial Responsibility

☐ I accept financial responsibility for all charges incurred
☐ I understand that my pet will not be released until payment is made in full

8.4 Cost Authorization Limits

☐ Do not exceed $[AMOUNT] without contacting me
☐ No spending limit; proceed with necessary care

8.5 Declined Recommended Services

I have declined the following recommended services:

☐ I understand declining recommended services may increase risks to my pet

SECTION 9: CONSENT AND ACKNOWLEDGMENT

9.1 Informed Consent

By signing below, I certify and acknowledge that:

☐ I am the legal owner of the pet named herein, or I am the authorized agent with authority to consent to veterinary treatment

☐ I have read and understand this entire consent form

☐ The surgical procedure(s) and reason for surgery have been explained to me

☐ The risks of anesthesia and surgery, including potential complications, have been explained

☐ Alternative treatment options have been discussed

☐ I have had the opportunity to ask questions and have received satisfactory answers

☐ I understand that no guarantee of outcome can be made

☐ I understand pre-operative fasting instructions and have complied

☐ I authorize the surgical procedure(s) and anesthesia described herein

☐ I authorize emergency treatment if complications arise during surgery

☐ I accept financial responsibility for all services rendered

☐ I understand I must be reachable by phone on the day of surgery

☐ I have provided accurate contact information

9.2 Witness

☐ Consent witnessed by: [WITNESS NAME]

SIGNATURES

CLIENT (Pet Owner or Authorized Agent):

Signature: _________________________________

Printed Name: _________________________________

Relationship to Pet (if not owner): _________________________________

Date: _________________ Time: _________________

Phone number for today: _________________________________

VETERINARIAN:

I have explained the surgical procedure, anesthesia risks, potential complications, alternatives, and expected outcomes to the client.

Signature: _________________________________

Printed Name: _________________________________

DVM License Number: _________________________________

Date: _________________ Time: _________________

WITNESS (Hospital Staff):

Signature: _________________________________

Printed Name: _________________________________

Title: _________________________________

Date: _________________ Time: _________________

FOR HOSPITAL USE ONLY

Pre-Operative Checklist

Surgical Notes

Surgery Start Time: _______________
Surgery End Time: _______________
Surgeon: _______________
Anesthetist: _______________

Intraoperative Notes:
[DOCUMENT SURGICAL FINDINGS AND ANY COMPLICATIONS]

Discharge Date/Time: _______________
Discharge Instructions Provided: ☐ Yes

This Veterinary Surgery Consent Form is provided for informational purposes only and does not constitute legal advice. Veterinary practices must comply with all applicable state veterinary practice acts and regulations. Consult with a qualified attorney before use.