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Referral Surgery Consent Form

Is your pet scheduled for surgery with Dr. Collins at your veterinarian’s hospital? Please read this form and complete all sections. This form must be completed at least 48 hours prior to your pet’s scheduled procedure.

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Referral Surgery Consent Form

Owner *

First

Last

Email *

Patient *

Date *

Referring Hospital *

Attending Veterinarian: *

Surgery to be performed: *

I consent to this surgical procedure for the above patient on this location.

Right
Left
Both
Not applicable

Surgical Risks May Include: 1. I have discussed the surgical procedure listed above with the attending veterinarian. I understand that there are risks and hazards involved with the recommended surgical procedure, including anesthetic risk. The attending veterinarian and referring hospital will be responsible for monitoring and recovering my patient during this anesthetic procedure. I realize no guarantee or warranty can ethically or professionally be made regarding the results or cure.
2. Infection, which may require additional testing and medication at an additional cost
3. Hemorrhage (bleeding) or bruising
4. Swelling or edema postoperatively
5. (If applicable) implant breakage or failure, requiring additional surgery at an additional cost

Adverse Drug Events (ADE). Any time any medication is given to a patient there is a possibility of an adverse reaction. This can range from something mild, such as nausea or a rash, to something life threatening. We monitor all patients given medications while in our care. If a problem develops it will be identified and treated as aggressively as possible. If your pet has had any known reactions to any medication in the past, please let someone on the team know.

Strict adherence to the post-surgical care and medicating of your pet will minimize these potential complications. Serious problems are very uncommon in most cases. Your pet will need to be under exercise restrictions until healing is confirmed by medical progress examinations, which may include anesthesia and radiographs (X- rays). Please do not allow your pet to return to full activity, bathe, run, play or swim until released by Dr. Collins or your regular veterinarian. Using the e-collar to prevent self-grooming is critical to avoid incisional infections.

Date *

Pet Owner/Agent Signature *

Clear Signature

Phone You Can Be Reached at Today: *

Date *

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Referral Surgery Consent Form

Referral Surgery Consent Form

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