Surgery Authorization FormOwner InformationName(Required) First Last Phone(Required)Email(Required) Pet InformationPet's NameBreedColorSexAgeWeightPresurgical BloodworkPreanesthetic Bloodwork Consent I CONSENT to preanesthetic bloodwork for my pet I DO NOT consent to preanesthetic bloodwork for my petFor young pets (under the age of 5) that are otherwise healthy and who are undergoing elective procedures, we recommend bloodwork (CBC and Chemistry) to ensure that there are no underlying conditions that would increase anesthetic risks. I understand that I will be charged accordingly for these tests, and the charge is present on my pet’s health care plan for today’s procedure. I understand that PT/PTT (a clotting panel) is required for all patients.Cardiopulmonary ResuscitationCardiopulmonary Resuscitation Orders: CPR is the resuscitation of an animal that has stopped breathing or has stopped breathing and whose heart is not beating. Resuscitation of an animal that has stopped breathing but still has a heartbeat is more likely to succeed than resuscitation of an animal with no breathing and no heartbeat. DNR means “do not resuscitate”. This is a decision that CPR is not to be performed in the event that the pet stops breathing or has no heartbeat. If you chose DNR and your pet stops breathing or his/her heart stops beating then we will not attempt to revive your pet and your pet will die. Animals that have survived cardiopulmonary arrest and have been successfully resuscitated (CPR) are extremely critical and unstable. Survival of respiratory arrest in which the heart has continued to beat carries a slightly better prognosis. The likelihood of re-arrest is high and usually occurs within 4 hours of the initial arrest. This means that there is only about a 20 % chance that your pet will stay alive for the first 4 hours after resuscitation. Long term survival is even more grave, and may be as low as 1%. Management of the post-arrest patient requires vigilant monitoring and the technical expertise of dedicated critical care personnel. This care is costly and the outcome is uncertain. If the pet is successfully resuscitated the doctors and staff will turn their attention to: providing cardiovascular and respiratory support. identifying and correcting any precipitating factors that led to the arrest. providing intensive monitoring so that therapy can be adjusted according to patient trends. this means that if your pet arrests and is resuscitated he/she will still have the underlying serious disease that lead to the arrest. That disease or injury must be treated as we attempt to stabilize your pet. The four systems that must be monitored closely and stabilized in post-arrest patients include the respiratory, cardiovascular, neurologic, and renal systems. Neurologic exams will be performed to evaluate brain damage. Brain damage is common and may last for days, weeks, or years. Blindness is common post-arrest. It may be temporary or permanent. Continuous monitoring is required to “trouble shoot” for other problems. Good prognostic indicators include stabilization of pulmonary function and blood gas values; normalization of lactate, acid/base, and electrolyte values; resolution of cardiac arrhythmias; normal coagulation parameters; normal urine output; and return of neurologic function.Signature(Required)I HAVE READ AND UNDERSTOOD THE INFORMATION ABOVE OR HAD IT EXPLAINED TO MY SATISFACTION.CPR Decision YES – CPR I wish the staff to perform CPR (resuscitation) on my pet if my pet suffers from cardiac or respiratory arrest. My pet may not respond to CPR or may respond initially and then suffer another arrest later. My pet may die despite CPR. The estimate for initial CPR is $500 to $1200. The estimate for the first 24 to 48 hours of veterinary care after CPR depends partially on pre-existing injury or illness and may be $1500 to $3500. Costs can greatly exceed this estimate. I understand that if my pet is critically ill, he/she may need to be transferred to Carolina Animal Specialty and Emergency if critical care is needed. I am responsible for all charges incurred. NO – DNR I DO NOT want CPR performed on my pet. I understand that if my pet stops breathing and/or his/her heart stops beating that my pet will die unless CPR is performed. I elect to have DNR orders placed on my pets record OR I elect that the veterinary staff stop the initial attempts at CPR that may have been started while I was being informed of the condition of my pet and my options.Signature(Required)I am the owner (or authorized agent of the owner) of the animal described above, and have the authority to execute this consent. I understand that some risk always exists with anesthesia, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian and understand that it may be necessary to provide additional medical or surgical treatment to my pet in the event of unforeseen circumstances. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. I hereby authorize the use of anesthetics and other medications, as well as any such additional treatment, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read, and fully understand, this consent. The fees associated with these services have been explained to me, and I agree to pay such fees at the time my pet is released from the hospital.CAPTCHAΔ
