Client Name *

First

Last

Patient Name *

Phone number at which owner can be reached the day of surgery *

Additional number *

Email *

Before Procedure:

Would you like to be contacted before your pet goes in for the procedure *

Yes
No

After Procedure:

Would you like us to call you after the procedure? *

Yes
No

Anesthetic and surgical procedure(s) to be performed: * *

I, the undersigned owner or agent of the pet identified above, authorize the staff of Wholehearted Veterinary Care to perform the above procedure(s). *

I have read and agree

Microchip: *There is an additional fee for this procedure *

Yes
No
Already has one

Nail Trim: Would you like a complimentary nail trim for your pet? *

Yes
No

Have you given your pets any medications or supplements in the past week? *

Yes, Presurgical Pack
Yes, Other medication(s), please specify below
No

When was the last time fed?

Any other concerns/allergies/procedures?

Anesthetic Procedures and Risks

At Wholehearted Veterinary Care, we use a combination of pre-anesthetic medications and injectable and/or inhalant anesthetics to obtain optimum levels of anesthesia for your pet. For short procedures, an injectable anesthetic is given alone, which produces an appropriate plane of surgical anesthesia with a quicker recovery time.

For most procedures, your pet is anesthetized and then intubated (insertion of a tube into the trachea or windpipe). This ensures your pet is able to receive oxygen at all times and prevents aspiration of any fluids into the lungs. Anesthesia is maintained with a gas anesthetic, Isoflurane, that is very safe and metabolized by less than 1% of the liver. Inhalant anesthetics allow us to have better control over anesthetic depth in our patients.

Monitoring and Pain Management

Patients under anesthesia are monitored in two ways. First, a veterinary assistant is with your pet from the introduction of anesthesia all the way through until recovery. Second, your pet's pulse, heart rate, oxygen level, ECG, respiration, and temperature are all tracked and displayed on a computerized monitor.

Being in pain is no fun. We take all necessary steps to ensure your pet’s pain is appropriately managed before, during, and after surgery. This will often include prescribed pain medication to take home post-operation.

Intravenous Catheterization and Fluids

We place an IV catheter and use IV fluids during almost all anesthetic procedures, with only a few exceptions. These allow for quicker recovery from anesthesia, as well as provide quick access to the circulatory system in case of an unforeseen emergency.

Potential Surgical Complications

Canine and Feline Spay

Bleeding
Infection
Recurrent Heat
Urinary Incontinence
Weight Gain
Suture Reactions

Canine and Feline Neuter

Bleeding
Infection
Testicular Swelling
Suture Reaction (Canine Only)

Tumor/Mass Removal

Bleeding
Infection
Swelling and Drainage
Suture Reaction

At Wholehearted Veterinary Care, we strive to provide the highest quality care for your pet. We will always provide you with our recommendations for appropriate precautions in order to avoid potential problems; however, it is important for all our clients to understand there is always an inherent risk of complication with any anesthetic or surgical procedure. We are thankful and honored that you have chosen to entrust the care of your pet to us.

I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. *

I have read and agree

I am over 18 and understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life sustaining procedures. *

I give my permission [yes]
I do not give my permission [no]

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 a failure to comply with the aftercare instructions. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above. * *

I have read and agree

Signature *

Date *

Form

Surgery consent form