Surgery and/or Procedure Consent Form

Please complete the form below and submit it to us in advance of your appointment.

Surgery and/or Procedure Consent Form

*ALL SURGERY PATIENTS MUST BE CHECKED-IN TO THE HOSPITAL BEFORE 9 AM* *SURGERY PATIENTS CANNOT HAVE ANYTHING TO EAT OR DRINK AFTER MIDNIGHT BEFORE THE PROCEDURE*
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Unless emergent, all surgeries are performed between 11 a.m. and 3 p.m. We will call as soon as your pet is out of surgery and awake from anesthesia. When we call, we will let you know when your pet can go home.
  • When your pet is scheduled for surgery, you can feel comforted that high-quality anesthetics and modern and efficient surgical protocols and methods used in our practice make routine procedures relatively safe, with a low rate of complications. Occasionally, problems can arise during anesthesia, even in healthy animals, regardless of age or breed. All animals presenting for procedures requiring anesthesia are given thorough physical exams prior to administration of any premedication or anesthetic. Anesthesia risks can be greatly increased due to preexisting conditions that are not or evident during a routine physical exam. Due to this fact, Shackleford Road Veterinary Clinic highly recommends that every patient be screened prior to anesthesia and surgery by means of a complete blood count, chemistry panel, and electrolyte panel. These tests are crucial for detecting:

    1. Low red blood cells or platelets which could cause a bleeding problem if not identified before surgery.

    2. White blood cell abnormalities which might lead to an increased risk of infection or delay healing.

    3. Abnormalities in liver function or kidney function that could lead to an adverse reaction to anesthesia.

  • PLEASE PERFORM A COMPLETE BLOOD COUNT, CHEMISTRY PANEL, AND ELECTROLYTE PANEL. Additional cost: $55 (Required in all patients over 7 years old).
  • Shackleford Road Veterinary Clinic will place an I.V. catheter and administer I.V. fluids during surgical procedures because: 1. Anesthesia causes blood pressure to drop which leads to low oxygen to the brain and body organs which in turn can cause damage to them. Fluid administration raises the blood pressure during anesthesia to counteract this. 2. In the event that an emergency arises, venous access is required for administering life-saving medications. A small patch of hair will be shaved on a front leg in order to place the I.V. catheter.
  • Please initial indicating your approval for the above-checked procedure.
  • Some pets will lick at their incision(s). If this occurs, we will place an e-collar on your pet and add the cost to your invoice.
  • Shackleford Road Veterinary Clinic uses the highest quality surgical materials and state-of-the-art equipment including a surgical Aesculight CO2 Laser. Advantages to surgery with the CO2 laser include:

    1. Ability to make more precise incisions with the laser allows for less pain and swelling after surgery and faster healing.

    2. Less bleeding from incisions made with the surgical laser make surgery safer for your pet.

    3. The sanitizing effect of the laser reduces the risk of infection after surgery.

    Due to the benefits listed above, all declaw procedures are done with the surgical laser; however, the laser can be used in almost all surgical procedures.
    Please perform CO2 laser surgery on my pet if recommended by the veterinarian (costs vary and start at $40).
  • Shackleford Road Veterinary Clinic strongly believes in compassionate, high-quality medical care for all of our patients. As a result, all surgery patients will receive pain management before surgery. To ensure that your pet has a comfortable recovery, we will prescribe pain medication to be sent home.
    I AUTHORIZE ADDITIONAL PAIN MEDICATION TO BE PRESCRIBED FOR MY PET AFTER SURGERY IF DEEMED NECESSARY BY THE VETERINARIAN (costs vary).
    Please indicate any additional services requested while here for your dental procedure:
  • I am the owner or agent of the above-described animal, I am at least 18 years of age, and I have the authority to execute this consent. I understand that Shackleford Road Veterinary Clinic requires my pet to be free from internal and external parasites and up to date on all vaccinations. I am financially responsible for all medical procedures and treatments, as well as for any cost associated with vaccination or parasite treatment and that this payment is due upon discharge. I understand that during the performance of the aforementioned medical procedure(s) and treatment(s), unforeseen conditions may be revealed that necessitate an extension of the aforementioned medical procedure(s) and treatment(s) than those set forth above, which may result in a change in the estimated cost. Therefore, I hereby consent to and authorize the performance of such medical procedure(s) and treatment(s) as are necessary and desirable in the exercise of the veterinarian's professional judgment. I also authorize the use of appropriate anesthetics and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. I have been advised of the nature of the medical procedure(s) and treatment(s) and the risks involved. I realize that results cannot be guaranteed. I have read and understand this authorization and consent. I hereby consent and authorize the veterinarians and staff of Shackleford Road Veterinary Clinic to render treatment, and by signing below agree to all conditions. I certify that if I am signing as owner/agent, that I have the authority to execute this consent.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.

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