RVAC Surgery Consent Form

Russell Vale Animal Clinic

17 Bellambi Lane
Bellambi, NS 2518

(024)284-5988

www.animalclinic.com.au

The Russell Vale Animal Clinic Hospitilisation/Surgery consent form

Please fill out the form as best as you can. Your submission of the form is the equivalent of your signature, saying that you understand and agree to what is being done to your pet, and that we have answered all and any of your questions.

If you have any questions, please ask them now before you submit the form.

Thanking you for understanding.

Dr Liz

12th April 2020

About you

Your first and last name (including any other surname your pet may be under)

Your Address

Your Phone number

Have you received an estimate? Yes or No. If no, we will email you an estimate prior to the day of the procedure. Yes (I have an estimate), No (please send me an estimate)

Email address (all discharge instructions will be sent to this address, please make sure russellvalevet@gmail.com is placed as a contact)

About your pet

Pet's name

What procedure is your pet having today

Additional Procedures

Are they any other procedures you would like done? For example, nail clips, check ears? Let us know. These may incurr an extra fee.

If not in the estimate, We have 3 tier blood tests (Miniprep incl PCV,TS, Glucose, urea, Urinesg cost -free, Prep (7 chem + full hematology ($125), Comprehensive(12 chem + full haematology) $170. Specify Prep or Comprehensive.

If not in the estimate, we do recommend all surgical procedures go onto intravenous fluids for extra support (Ketamine CRI) Cost $90.00 Yes or No

Time last fed

Is your pet on any medications, supplements or treatments in the past seven days. Yes/No - if yes, what are they

Surgery consent questions (Yes/No)

Has your pet ever had a past anaesthetic event that you thought went poorly? Yes/No

Has there been any.... (Yes/No) - if yes, please tell us more

Vomiting Yes/No

Coughing Yes/No

Trouble breathing Yes/No

Diarrhea Yes/No

Fits/Epilepsy/Unusual Turns Yes/No

Allergies/Reactions to medications? Yes/No

Illness/Injury in the past 30 days? Yes/No

Anything that may affect the anaesthetic or your pet's recovery from the procedure recommended?

Change in appetite Yes/No

Change in the amount they drink Yes/No

General Health questions

Is your pet current on....

Heartworm prevention? If so, what do you use

Flea/Tick Control? If so, what do you use and when was it last given

Vaccinations?

Do you anticipate that there will be any problems keeping your pet reasonably quiet during recovery? Yes/ No. Any special requests for sedation or e collars can be made here.

Consent for CPR

If there is an adverse event, if we are unable to contact you within 20 minutes after initiating CPR, or if after exercising reasonable medical judgement that there is no hope for success, the staff will cease further CPR.

Please perform CPR - Yes (fees apply) No

Final consent

I consent for my pet to be admitted to hospital for the above procedure, and I submit this form stating that I am comfortable with the information that has been given to me about the risks associated with the proposed treatment or surgical plan.

Check the reCAPTCHA to
ensure you are not a robot :