Surgery Form

Date

Name

First

Last

Phone

Patient's Name

Is your pet coughing/sneezing/vomiting/has diarrhea?

Yes

Is your pet eating and drinking normally?

Yes

What kind of food do you feed your pet?

When was the last time your pet ate?

What medications is your pet on and what time were the last doses given?

Any other concerns for the doctor while your pet is here?

If your pet needs a cone after surgery, which type to you prefer?

Clear Plastic

Soft Washable

I elect endotracheal intubation, positive pressure respiration, administration of emergency drugs, and/or external cardiac massage.

I elect NOT to have staff pursue any CPR procedures for my pet. Instead, I request that the attending veterinarian assist my pet in humane euthanasia if treatment will only prolong pain and suffering in the veterinarian’s medical opinion.

If I request such emergency procedures, I agree to be held responsible for veterinary services provided to my pet while staff members pursue treatment and try to reach me for further directions.

I accept that if the hospital staff is unable to reach me within 20 minutes after initial CPR procedures, and after exercising reasonable medical judgement, determine that there is no hope for success, the staff will cease further CPR procedures.

I understand that despite the best efforts of the doctors and support staff at Shawsheen Animal Hospital less than 5% of animals that require CPR fully recover to leave the hospital.

I have read and understand my options as outlined above and agree to pay all costs associated with the emergency treatment of my animal.

If your pet is here for a lumpectomy, we will ask you to point out the lumps to be removed; you may save time by marking them with a sharpie or lipstick at home. Shawsheen Animal Hospital is to use all reasonable precaution against injury, escape, or death of my pet. I understand that any anesthesia involves some minimal risk to my pet, but Shawsheen Animal Hospital will not be held liable or responsible in any manner whatever or under any circumstances in connection therewith as it is thoroughly understood that I assume all risks. Signature

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Sedative/Anesthesia Release

In the event that my pet needs additional treatments while under anesthesia (dental extractions, etc) I understand that Shawsheen Animal Hospital will make every reasonable attempt to contact me using the numbers I have provided. In the event that I am not able to be reached:

I authorize Shawsheen Animal Hospital to perform whatever additional services necessary that are in my pet’s best interest. I realize that this will increase the total of my invoice.

I do not authorize Shawsheen Animal Hospital to do anything beyond what was quoted in the original estimate. I understand that by denying this authorization, the possibility exists that my pet may need to return for another surgery in the near future, thereby incurring additional charges for anesthesia, etc.

Date

Shawsheen Animal Hospital is to use all reasonable precaution against injury, escape, or death of my pet. I understand that any anesthesia involves some minimal risk to my pet, but Shawsheen Animal Hospital will not be held liable or responsible in any manner whatever or under any circumstances in connection therewith as it is thoroughly understood that I assume all risks. I have read the foregoing and agree. Owner Signature

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Sedative/Anesthesia Release

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