Anesthetic & Surgical Release Form – Veterinarians Lewisburg Tennessee

Owner's Name*

First Last

Pet's Name*

Species

Contact Phone #1*

Contact Phone #2

Scheduled Procedures*

Additional Procedures or Treatments

(Examples: Nail Trim, anal glands, vaccines, fecal)

Medical History*

(Current Medications, Medical Conditions, Anesthetic History, etc.)

Were you given an estimate for today's procedure(s)?

Do you want an estimate?

 Rabies vaccine is required for all pets unless deemed a health risk by a doctor. Must present documentation.  If diagnosed with internal or external parasites while in our care your pet will be treated at an additional cost.  If your dog is being spayed and is in estrus (heat) there will be an additional fee.

Is your pet current in the following areas?

Rabies (Required)*

Yes
No

Do you want to update today?*

Yes
No

DA2PPV + - Leptospirosis*

Yes
No

Do you want to update today?*

Yes
No

FVRCP*

Yes
No

Do you want to update today?*

Yes
No

Leukemia*

Yes
No

Do you want to update today?*

Yes
No

Leukemia/FIV Testing*

Yes
No

Do you want to update today?*

Yes
No

Bordetella*

Yes
No

Do you want to update today?*

Yes
No

Heartworm Testing + Prevention*

Yes
No

Do you want to update today?*

Yes
No

Flea/Tick Prevention*

Yes
No

Do you want to update today?*

Yes
No

Fecal Testing*

Yes
No

Do you want to update today?*

Yes
No

Microchipping*

Yes
No

Do you want to update today?*

Yes
No

Deworming*

Yes
No

Do you want to update today?*

Yes
No

Your pet’s health is our primary concern. We have outlined the components of your pet’s procedure today so that you can better understand and make the appropriate choices for your pet’s health and safety. Most estimates will have an IV catheter, blood screening and pain management included as we require them for most surgical procedures other than spays and neuters. Your pet will receive a pre-surgical exam before anesthesia is performed. The purpose of this exam is to make sure that your pet is in the best physical health possible before anesthesia is administered. During the pre-anesthetic exam or during the procedure, the doctor may discover that unexpected procedures/treatments are needed. In this instance, every effort will be made to contact you. If we cannot contact you, we will not perform additional procedures/treatments. We use Isoflurane gas that is often used in human medicine. Isoflurane is primarily eliminated through the respiratory tract rather than through the kidneys or liver helping to reduce the risks associated with anesthesia and allowing for a quick recovery. Your pet’s temperature, heart rate, respirations and oxygen levels are continuously monitored by one of our nursing staff and monitoring equipment throughout the entire procedure. Intravenous Catheter with Fluids: General anesthesia lowers blood pressure which can compromise organ function. The best way to counteract this is to provide fluid support intravenously. To do this a small area on the front leg must be shaved and an IV catheter is placed. Your pet will receive IV fluids during the procedure, which will improve maintenance of blood pressure. An IV catheter also provides the ability to give emergency drugs more quickly if needed. We recommend an IV catheter and fluids for every patient, but do not require it for routine procedures in young animals. Pre-Anesthetic Blood Screen: Our on-site laboratory lets us screen for underlying health problems that may not be physically evident and that can put your pet at higher risk for anesthetic complications. Therefore, pre- anesthetic blood screening is highly recommended to ensure that major organ functions are normal. This does not eliminate all anesthetic risks but provides us with a broader scope of your pet’s health and internal function. We recommend pre-anesthetic blood screening for all our patients, but do not require it for routine procedures in young animals. Pain Management: Pet’s experience pain just like people do. Your pet’s comfort is important to us and we believe alleviation of pain expedites the healing process. We recommend pain medication for all our patients.

Procedure Options

Consent

I have received an estimate for procedure(s) being performed today. I understand that this estimate may not include unforeseen complications that would require additional treatment. I have read the estimate and agree.

Consent

I decline an estimate for procedures being performed today.

I elect to have an IV catheter with fluids. (Call for updated pricing)
I decline an IV Catheter with fluids
I elect to have pre-operative bloodwork. (Call for updated pricing)
I decline pre-operative bloodwork.
I want pain medication for my pet (Call for updated pricing)
I decline pain medication for my pet.

Consent

I understand that in some instances an IV catheter, bloodwork or pain medication may be deemed necessary for my pet’s safety and comfort. In this case I understand that I will be responsible for the additional cost and will be notified before the doctor proceeds. If an IV catheter, bloodwork or pain medication is included in the estimate without the option to decline then they will be performed but will remain within the limits of the estimated cost.

Consent

I understand that it’s possible that the doctor may find additional medical issues that need to be addressed while my pet is under anesthesia. If I am unable to be reached by my preferred method of contact, I want the doctor to proceed as defined below.

Amount ($)

Authorization

Authorization and Risk Assessment*

I agree

I understand that during anesthetic procedures great care is taken to ensure my pet’s health, but unforeseen conditions may be revealed that necessitate an extension or variance in the procedure(s) defined above. I authorize Lewisburg Animal Hospital to perform any treatment or surgical procedure(s) deemed necessary for medical or surgical complications or any unforeseen circumstances. While Lewisburg Animal Hospital provides the highest quality of anesthesia monitoring and surgical services, I understand the risks and understand that the veterinarians and hospital team will do everything possible to reduce any risks. I will not hold Lewisburg Animal Hospital, the veterinarians or any team member liable for any complications that may arise. By signing this document, I certify that I have read this document, understand it, and have had all my questions answered to my satisfaction and I agree to the conditions of treatment. My signature below authorizes the doctors at Lewisburg Animal Hospital to perform approved procedure(s) and or treatment(s) described on page 1.

Date