URLThis field is for validation purposes and should be left unchanged.Owner's Name*Phone Number*Your Email* Emergency ContactPet's NameSexMaleFemaleAgeDid You Withhold Food?YesNoList Current MedicationsGeneral Anesthesia Basic pre-anesthetic lab work including Body Chemistry Function Parameters and a Complete Blood Cell Count is completed on ANY pet 7 years or older undergoing general anesthesia.If your pet is under 7 years old blood work is optional for today's procedure Please select from below: Yes, I consent to have Basic pre-anesthetic lab work completed No, I decline to have Basic pre-anesthetic lab work Pain Medication: Injectable pain medication is given to every pet undergoing a surgical and/or potentially painful procedure at TVH: this is NOT OPTIONAL. Additional pain medication is routinely prescribed post-surgery and is part of your care plan. Please select from the following:PillsLiquid MedicationsNo PreferenceRequired Preventative Care: All animals admitted at TVH must be current on a Rabies vaccine and free of external parasites. Any animal found to have fleas or ticks will be treated at the owner's expense. Dental Procedures ONLY: While under anesthesia, more advanced dental disease can sometimes be found. If additional extractions are recommended, how would you like to proceed? Please proceed with ALL doctors recommended extractions Call me first. If I cannot be reached, please proceed with doctors recommended extractions. Call me first. If I cannot be reached, please do nothing beyond the care plan. I understand this may require another procedure. Care Plan: A detailed care plan is presented at your pet's admission. If you did not receive a care plan for your pet's procedure, please ask your veterinary technician. Care plans for procedures can change at the Doctor's discretion depending on the pet's condition, need for additional diagnostics, medications, complications or longer surgical time. We will attempt to call you at the above-listed number if any significant changes to your care plan are anticipated. Optional Services: If your pet has been admitted for mass removal, we highly recommend sending a sample for a histopathology, which will determine if the mass is cancerous. This test is at an additional cost and can be added to your care plan. Yes, I consent to have a histopathology No, I decline to have a histopathology Would you like a free nail trim today? Yes No We recommend the use of a post-surgical collar for specific surgeries. Do you need a collar today? Yes, I will need one added to the care plan No, I have one that I would like to use CPR Consent: Should unexpected life-saving emergency care be required, and the attending veterinarian is unable to contact me: I consent to and authorize resuscitation of my pet: including, but not limited to, CPR, fluids, and the administration of life-saving drugs. I decline resuscitation of my pet: do not perform any resuscitative measures on my pet. I hereby authorize anesthesia/surgery for my pet. I understand that some risks always exist with anesthesia and/or surgery. My signature on this consent form indicates that any questions have been answered to my satisfaction. While Timberland Veterinary Hospital provides the highest quality of anesthesia monitoring and surgical services, I understand that there are rare complications associated with any anesthetic or surgical procedure. In particular, I have been advised that there is an extremely small risk of death, complications, or side effects (which can present themselves well after the procedure) every time an anesthetic is used and that I have been advised of the possibility. I acknowledge these risks and understand that the veterinarians and hospital staff will try to minimize such risks. I will not hold Timberland Veterinary Hospital, P.L.L.C, the veterinarians, or any staff member liable for any complications that may arise.
