Name: Veterinarian
Brand: Valley West Veterinary Hospital

Client Information

Client Name:

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number:

Email Address:

Patient Name:

Species:

Breed:

Sex:

Male

Neutered

Female

Spayed

Color:

Markings:

Birth Date / Age:

By Signing this document you certify that you own or have permission of the owner to consent Valley West Veterinary Hospital and its staff to hospitalize, administer treatments, and perform procedures deemed necessary by the attending veterinarian for the welfare of your pet. I also understand that by signing I am taking full responsibility for payment, treatments, and procedures upon discharge of the pet. I further understand that no guarantee of successful therapeutic or diagnostic outcome is made.

I. ADMISSION REQUIREMENTS:

In order to be admitted for surgery, your pet must be up to date on his/her wellness exam and necessary vaccines (Rabies, Bordetella, DHLPP, and FVRCP). We require proof of vaccines If not given by us directly, thank you. Please e-mail proof of vaccines at: staff@elkvalleyvets.com and staff@valleywestvets.com

Vaccines Needed:

Routine Medications:

Please list all daily medications. When were they last given?

II. PRE-ANESTHETIC EXAMINATION AND BLOOD TESTING:

Although most animals tolerate anesthesia, there is an inherent risk, even in healthy pets. To provide the best conditions possible for anesthesia, a veterinarian first assesses your pet during a pre-surgical exam. This exam is important and provides a portion of our pets health status. In addition, we require a pre-surgical blood panel, similar to what humans receive, to obtain a further diagnostic picture of your pets health. The reason for this panel is two-fold: 1) Blood tests might reveal hidden abnormalities that would put your pet at greater risk for anesthetic complications. In this case, we would postpone surgery and recommend needed treatment. 2) This panel would serve as a reference (what is normal for your pet) as your pet ages, becomes ill, or needs possible emergency treatment in the future. We also recommend an ECG with the procedure that gets sent off to a cardiologist for a more in depth heart exam.

Due to the length of anesthesia for these types of procedures, one of the following is required:

I would like my pet to have pre-anesthetic lab work and ECG.

I would like my pet to have pre-anesthetic lab work

III. PAIN MANAGEMENT POLICY:

To allow your pet to rest comfortably after surgery we routinely administer an injection post-surgery to relieve discomfort and pain. Additional pain medications will be prescribed and sent home with you at the doctor's discretion.

IV: ANESTHESIA CONSENT:

I authorize Valley West Veterinary Hospital to perform a procedure on my pet that requires general anesthesia. I understand that results cannot be guaranteed, and that anesthesia and surgery always carry potential risks to the life and health of my pet. I am aware that in rare cases, medical complications may arise which will be treated in prompt and aggressive manner by the medical staff of Valley West Veterinary Hospital, including but not limited to the use of emergency drugs, cardiac compression and artificial respiration. I assume full financial responsibility for this animal, for all the procedures required and requested either on this form or by phone.

I Agree

V. ELIZABETHAN COLLAR:

Every patient that has an orthopedic procedure will be sent home with an Elizabethan Collar (soft cone that goes around pets head) to prevent licking and reduce the chances of post-op infection and incisional complications. If the Elizabethan collar is not worn you may be responsible for any charges that incur due to complications from not wearing it. Do you understand and accept this policy?

Yes, I agree and accept this policy.

VI. Please list the procedure that will be performed today:

Procedure:

VII. Please indicate which limb we will be performing surgery on:

Limb:

In the event that your pet experiences cardiac or respiratory arrest while under our care, do you consent to the veterinary team performing Cardiopulmonary Resuscitation (CPR) in an attempt to revive your pet? CPR may include chest compressions, artificial ventilation, and emergency medication. Please note that while CPR can be life-saving, it does not guarantee recovery and may involve additional costs. Kindly indicate your preference by selecting the appropriate option below, understanding that this decision is critical in an emergency situation.

Owner Signature

Sign above

I give Valley West/Elk Valley permission to post pictures of my pet on their social media accounts? I understand that these images may be used for promotional purposes, and I agree to allow their use without compensation.

Yes

Orthopedic Anesthesia/Surgery Consent Form