Procedure Consent Form "*" indicates required fields LinkedInThis field is for validation purposes and should be left unchanged.Owner Contact InformationPet Owner Name* First Last Pet Owner Phone Number*Please enter a phone number you can be easily reached at on the day of the procedure.Email* Pet Owner Address* Street Address Address Line 2 City Province Postal Code Pet Information DetailsType of Pet*CanineFelinePet Breed*Pet Name*Pet Age*Procedure DetailsProcedure*NeuterSpayDentistryMass RemovalMisc.Date of Scheduled Procedure* MM slash DD slash YYYY Pet Owner ReleaseI hereby certify that I have read and fully understand this authorization for treatment. I am the owner or agent for the above-described animal, am at least 18 years of age and have the authority to execute this consent. If unforeseen conditions arise which, in the judgement of the attending veterinarian, call for procedures or treatments other than those now being authorized, I authorize such procedures if reasonable efforts to contact me for further consent are unsuccessful. I understand that I am responsible for the additional charges should additional procedures be required. I understand some risks always exist with medication, procedures, anesthesia and/or surgery, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) is initiated. My virtual signature on this consent form indicates that any questions have been answered to my satisfaction. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures.In the event of a life-threatening emergency, my wishes are Yes, I consent to performing resuscitation/CPR. No, I do not consent to CPR measures for resuscitation. Disclaimer: For the safety of all patients, we ask every client to indicate their wishes regarding CPR in the rare event of an emergency. This is a standard precaution included on all consent forms and does not reflect any specific concern about your pet.Consent I HAVE READ AND FULLY UNDERSTAND THIS CONSENT FORM. I have had the fees outlined to me and agree to pay all such fees and charges at the time of discharge.Date MM slash DD slash YYYY Pet Owner Signature* Please type your full name for acknowledgement of consent. Social Media ReleaseConsent I hereby grant Ilderton Pet Hospital, its employees, or agents permission to take photographs, and/or videos of my pet, and to identify my pet by name. I authorize the Hospital to copyright, use and publish those photographs or videos for any lawful purpose, including, but not limited to, their website, social media accounts, and promotional materials, either digital or in print, in perpetuity. If you do not wish to provide consent, please do not sign.Pet Owner Signature Please type your full name to confirm acknowledgement and understanding. AnesthesiaConsent for General Surgery & Dental Procedures* The night before the procedure, Instead of feeding a full breakfask will feed a maximum of 1 tbsp of canned food or 1 tbsp of a moistened mash of kibble before 6:30 am. I will remove access to water and further food at 6:30 am the morning of the procedure.Pet Owner Signature* Please type your full name to confirm acknowledgement and understanding. Cerenia* I will administer the prescribed Cerenia (an anti-nausea medication) 2 hours prior to surgical drop-off. If that timing does not work, I will give it at bedtime the night before.If you were not provided with a dose of Cerenia in preparation for your pet’s procedure, please contact the clinic. Cerenia helps reduce nausea and supports a quicker return to appetite after surgery.Pet Owner Signature* Please type your full name to confirm acknowledgement and understanding. Calming Medication If dispensed, I will administer the prescribed calming medication as directed on the prescription label.Calming medication may be prescribed to help reduce any fear or anxiety your pet may experience. This medication can be administered the night before the procedure and again in the morning, approximately 2 hours prior to admission. If you were not provided with calming medication and feel your pet may benefit from it, please contact the clinic.Pet Owner Signature Please type your full name to confirm acknowledgement and understanding. Health ConcernsConsent* I will inform the admitting staff member of any new changes or concerns with my pet's health when dropping them off for the procedure. If any health concerns arise prior to the procedure, I will contact the Hospital and inform a staff member.Pet Owner Signature* Please type your full name to confirm acknowledgement and understanding. Does your pet require a special diet due to food allergies or sensitivities?* YES NO If yes, please note the diet below and bring a meal-sized portion for us to feed once they’ve recovered from the procedure.*Dental Procedures **This section is only to be signed if your pet is coming in for a dental procedure. Please disregard this section if not applicable**Many oral health issues can not be detected until a thorough dental exam is performed under anesthetic. I understand that there may be additional extractions or dental procedures required that were not initially noted during the clinical exam. Complications of dentistry are rare but can include hemorrhage, nerve injury, destabilization or fracture of the jaw, retained root material, loss of teeth adjacent to the extraction and infection.If additional extractions are required, I would like to be called before they are performed. YES NO Pet Owner Signature Please type your full name to confirm acknowledgement and understanding. Dental X-Rays **This section is only to be signed if your pet is coming in for a dental procedure. Please disregard this section if not applicable**Full-mouth dental X-rays are strongly recommended to properly assess and diagnose dental conditions that cannot be fully evaluated without imaging below the gumline. If you decline full-mouth X-rays, we will base our treatment on the findings from the oral exam, but this approach may overlook dental issues hidden beneath the gumline. Alternatively, a single-view X-ray is available to focus on visibly concerning teeth, though this may not detect underlying issues in teeth that appear healthy. Do you consent to full mouth dental x-rays? YES NO **If your pet is scheduled for an Early Intervention Dentistry, please note that full-mouth x-rays are a required part of the procedure and are included in the program. They are not optional.**Pet Owner Signature Please type your full name to confirm acknowledgement and understanding. If the doctor recommends single-view X-rays to further evaluate questionable teeth, I request to be contacted before they are performed. YES NO Pet Owner Signature Please type your full name to confirm acknowledgement and understanding. Pediatric Anesthesia Procedures **This section is only to be signed if your pet is coming in for a pediatric anesthetic procedure (i.e., a spay or neuter). Please disregard this section if not applicable**In the event that persistent deciduous teeth are noted, I consent to extraction of the retained baby tooth while under general anesthesia. YES NO In some cases, the baby teeth do not fall out and both the adult and baby tooth are contained in one socket. These are called persistent deciduous teeth and can pose a problem for long-term dental health if they are not addressed.Pet Owner Signature Please type your full name to confirm acknowledgement and understanding. Would you like a microchip implanted while your pet is under anesthesia? YES NO My pet already has one Please refer to your estimate for pricing details or contact the clinic if you have any questions.Pet Owner Signature Please type your full name to confirm acknowledgement and understanding. Would you like a pre-anesthetic bloodwork panel completed prior to your pet's procedure? YES NO We recommend performing this diagnostic testing 1-2 weeks prior to your pet’s surgery to ensure they are a good candidate for the procedure. This bloodwork helps to ensure they have normal blood cell counts and healthy internal organ function, enhancing the safety of the procedure and reducing the risk of complications. We can also perform this the morning of their procedure if preferred. Please refer to your estimate for pricing details or contact the clinic if you have any questions. Pet Owner Signature Please type your full name to confirm acknowledgement and understanding. ConclusionThe day before the procedure, one of our technicians will be reaching out to review the estimate, confirm a drop-off time, and answer any questions you may have. This phone call typically takes place in the afternoon. Please detail any times you may be unavailable for a phone call on this day:If you have any questions or concerns you would like addressed prior to this phone call, please do not hesitate to reach out via phone or email. We look forward to seeing you and your pet soon!Sincerely, The Veterinarians & Staff of Ilderton Pet Hospital
