Detroit Lakes Animal Hospital

1115 West River Road
Detroit Lakes, MN 56501

(218)847-5674

www.detroitlakesanimalhospital.com

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Surgical & Anesthesia Consent Form Form

Label
Name
First Name
Last Name
Breed

DOB :
Selection
M
F
Microchip Number

Client Number

Client Name

Procedure:
I certify that I am the owner/guardian of the pet described above and have full authority to execute this consent. (Initial below)
I certify that my pet has not eaten in the last 8 hours as recommended. (Initials below)

I give my full consent to have the veterinarians of the Detroit Lakes Animal Hospital to perform the surgical procedures listed below. (List Procedure(s) and Initial)

Surgical Bloodwork: Your pet’s risk of complications during and after anesthesia and surgery is tremendously greater if there is preexisting organ disease, malfunction, or failure.
We strongly encourage blood work before anesthesia and surgery to help rule out these problems or identify them and devise an alternative treatment plan to meet your pet’s unique needs.
Adult Profile $128.00 – Chemistry Profile + Complete Blood Cell Count (CBC) (Initial below to consent for this test to be performed)

Canine Senior Profile $175.00 – Chemistry Profile + CBC + Urinalysis (Initial below to consent for this test to be performed)

Feline Senior Profile $193.00 – Chemistry Profile + CBC + Urinalysis + Thyroid (Initial below to consent for this test to be performed)

I DECLINE the recommended pre-anesthetic tests and request that you proceed with anesthesia. I understand that a medical condition may exist which would be impossible to identify during a physical exam alone and my pet's health could be at risk.

Anesthetic/Surgical Risks:
These may include and are not limited to hemorrhage, hypothermia, decreased heart rate or respiratory rate, death, post-operative complications (i.e. surgical site breakdown, implant failure/rejection, secondary infections), etc.
I understand these risks and that the doctors and supporting staff of Detroit Lakes Animal Hospital will do their best to minimize said risks. (Initial below)

Resuscitation Orders:
In the event my pet’s heart and/or breathing stop (cardiopulmonary arrest), resuscitation efforts according to the advanced directive below will be undertaken by the doctor(s) and/or staff of Detroit Lakes Animal Hospital.
We will perform our best to resuscitate your pet, however CPR success rates are ~13-15%. Furthermore, I understand that I will be responsible for any costs incurred in performing these measures:
Do NOT Resuscitate (Red Code) – No medical intervention to save my pet . Initials Below:

Close-Chest CPR (Yellow Code) – Heart compression, artificial respiration, meds and/or fluids Initials Below:

Post-Surgical Pain Management:
The anesthetic protocol chosen by our doctors provides relief from pain during and up to 4-6 hours after surgery. For this reason, your pet should be comfortable, although possibly a little drowsy, upon discharge.
Pain medications will be sent home to be used after almost all surgical procedures for continued pain relief.
I authorize the doctors and supporting staff of Detroit Lakes Animal Hospital to perform services, diagnostic procedures, and treatments deemed necessary to improve my pet’s quality of life and provide quality veterinary care.
I authorize the use of all anesthetic agents, sedatives, tranquilizers, and other medications and supportive care before, during, and after my pet’s procedure.
I understand that hospital support personnel will be employed as deemed necessary by the attending veterinarian.I have been advised of the risks and possible complications of my pet’s procedure and that results and/or expected outcome cannot be guaranteed
I understand that payment is due at the time of service and that I am fully financially responsible for any and all services rendered.
I also agree to pay for all expenses incurred to collect the debt including, but not limited to, attorney fees, collection agency fees, and billing fees.
Signature of Owner/Guardian/Agent (Please type your full name)

Date :
Phone
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