Surgery/Dentistry/Anesthesia Consent Form Surgery Consent Form Please fill out this form in entirety to ensure we can provide your pet with the best possible care. Preferred Location * Any LocationElmhurstHinsdale Who is your pet seeing today? * Select OneDr. Sarah BakerDr. WeberDr. KanakTeam/NurseNot Sure Pet's Name * Name Name First First Last Last Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email * It is imperative that we be able to reach you in a timely manner while your pet is in the building today. Please have your cell phone listed above available and be free to talk. Where can we call you at while your pet is here? * Is there anyone else we can call regarding your pet while they are here today? * Yes No Section Alternative Contact Name Alternative Contact Name First First Last Last Alternative Contact Phone Reason for your pets visit today? Please list type of surgery. For example: lump removal, cystotomy, dental, etc. Has your pet had any food since midnight last night? * Yes No Unsure If yes, please describe/provide more information Has your pet been vomiting or having diarrhea? * Yes No Unsure If yes, please describe/provide more information Does your pet have any allergies? * Yes No Unsure If yes, please describe/provide more information Has your pet ever had any adverse reaction to medication? * Yes No Unsure If yes, please describe/provide more information Please list any medications, supplements, topical treatments your pet has received in the past 72 hours and when they were last given When Was Your Pet's Last Dose of Flea/Tick Preventative? * Date Given (Please type N/A if not on a preventative) What Kind of Flea/Tick Preventative Do You Use? * Name of medication - put unknown if not sure Is Your Pet Current On Vaccinations? * Yes No Unsure My pet's vaccines were administered last by * At Lane Veterinary I Am Not Sure Where OtherOther Would you like your pet microchipped during their procedure? * Yes No Would you like your pet sent home with the pheromone calming collar that was listed on your estimate? FOR DOGS ONLY * Yes No In an effort to provide your pet with the highest quality surgical care, we offer therapeutic laser as an option for all surgeries. The laser helps reduce inflammation and promote healing faster. * Yes, I would like the therapeutic laser to be used for my pet. No, I am declining the therapeutic laser at this time. If the procedure requires a surgical suit or e-collar, which would you prefer? * Surgical suit E-Collar No preference Please note, a surgical suit may not be an option for all surgical procedures. Is There Anything Else We Should Know About Your Pet? If yes, please tell us more. If no, please note N/A Authorizations I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize treatment of my pet to be performed by Lane Veterinary. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian. * I verify Only applicable for spay/neuter: I understand a small tattoo will be placed on my pet's abdomen after a spay or neuter procedure. This is to identify my pet as having been spayed/neutered. The purpose of this procedure has been explained to me by a veterinarian or Lane Veterinary staff member. I understand Only applicable for dental procedures: For any dental procedure I understand oral surgery (extractions) may be necessary and can sometimes only be determined after my pet is under general anesthesia. I hereby consent to and authorize the performance of such procedures as are necessary in the veterinarian's professional judgement. I accept responsibility for any result in additional charges. I agree I have been advised as to the nature of this procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any sedation or anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian and/or team members have provided me the opportunity to ask questions and receive answers regarding the procedure. This risk includes serious bodily injury or death. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. * I accept responsibility for any result in additional charges I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital). * I agree to be responsible for all charges In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference * Please proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred. Please do not proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred. I acknowledge my choice regarding resuscitation choice for my pet as noted above. * I acknowledge Signature * signature keyboard Clear Submit If you are human, leave this field blank.
