Surgical Pre-Admission Form Surgical Pre-Admission FormPlease complete all required areas prior to your appointment. If you have any questions or concerns, don’t hesitate to contact us. Pets Name * Species * Breed * * Male Female Approximate Age of Pet * Color * Owner's Name * First Name Last Name Owner's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Owner's Phone Number * (###) ### #### Owner's Email * I give Auburn Hills permission to contact me via text * Yes No I give Auburn Hills permission to email my email address listed above * Yes No Date of Surgery * MM DD YYYY Is the pet currently on any medications or supplements? * Yes No If yes to previous question, please list medications and/or supplements Has your pet been vomitting or had diarrhea? * Yes No Has your pet had normal urination/defecation? * Yes No Has your pet been eating and drinking normally? * Yes No Has your pet ever had a reaction to any medication or vaccination? * Yes No Has your pet ever had a seizure? * Yes No If female, is there a chance your pet could be pregnant? * Yes No Is your pet in need of heartworm, flea and tick prevention? * We will send this home with you. Yes No If yes to previous question, please list the amount and brand of heartworm and/or flea/tick prevention. If your pet is new to our clinic, are they due for vaccines? * Yes No If yes to previous question, please provide most recent vaccination information. If your pet is due for vaccinations, would you like us to complete them at this time? * Yes No If you are due for any refills on food, medication, etc. please list that here. Does your pet have any baby teeth that need extracted? * Yes No Does your pet have any dewclaws that you want removed? * Yes No Like you, our greatest concern is the well-being of your pet. We highly recommend blood screening before any surgical procedure involving anesthesia. There is a cost associated with this test. Would you like to run pre-anesthetic blood testing? * Yes No Signature Required * First Name Last Name Laser therapy accelerates the body’s natural healing process. It reduces inflammation and increases blood flow to surgical site. Would you like us to perform laser therapy on the surgical site? There is a cost for this procedure. * Yes No Signature Required * First Name Last Name Would you like a Home Again Microchip inserted today? There is a cost associated with this. * Yes No SIgnature Required * First Name Last Name Are we removing any type of Cyst or Mass? * Yes No If yes to previous question, please describe as detailed as possible the location of the cyst/mass. Upon removal of the tissue from the cyst or mass, do you wish to have the sample sent in for testing? There is a cost for sending this sample in. * Yes No N/A Signature Required * First Name Last Name Any other concerns we should be aware of or any other procedures you would like completed? Potential Complications of Anesthesia Incisional Dehiscence/ Infection: An incision is made through the skin, fat layer, and abdominal wall to remove the uterus. This incision is closed with multiple layers of internal sutures (+/- external sutures). Excessive activity or licking at the incision can cause the incision to become infected and affect the integrity of the sutures resulting in opening of the incision. An additional surgery may be necessary to correct the life- threatening infected incision or dehiscence. Ligature slippage: The vessels that provide the blood supply to the ovaries and the uterus are either ligated (tied off) with suture or cauterized during the spay procedure. Even though each ligature or suture is checked multiple times during surgery, there is a small risk that the ligature may slip off the end of the vessel causing internal bleeding. Ovarian remnant/Stump pyometra: An ovarian remnant occurs when a small portion of the ovarian tissue remains in the abdomen due to ectopic tissue or incomplete removal of the ovarian tissue. This can occur if the tissue can produce hormones and cause another heat cycle, but they are not able to get pregnant. This is a higher risk in obese or older animals. Another surgery would be necessary during a heat cycle to find the remaining portion of the ovary. If an ovarian remnant is present to produce hormones, a stump pyometra (an infection of the small portion of uterus remaining) can occur. Urinary Incontinence: Urinary incontinence may occur in 4-20% of spayed female dogs usually within 3 years of the procedure. This condition is caused by multiple factors relating to the lack of estrogen produced by the ovaries. This can usually be controlled with medication. Cranial Cruciate Ligament Rupture: Spaying of large breed dogs in particular at a young age causes delayed closure of the physis or growth plates resulting in longer bones and steeper angles within the joints; consequently, a higher number of cranial cruciate ligament ruptures are seen. Overnight communication: If your pet stays overnight, our phones are turned off from midnight to 8 a.m. the next morning. No news is good news overnight. If there is an emergency that involves your pet, you will be called by the technician or the doctor depending on the circumstance. The doctor will perform a morning exam between 8 am and 10 am and again, no news is good news. Intravenous Fluids: Usually, your pet is placed on IV fluids when in the hospital to treat dehydration or to provide a way to medicate your pet. In rare occurrences, too much fluid can be administered that can build up in the lungs causing difficulty breathing, but they are monitored closely to prevent complications caused by excess fluids. Consent Section I, the undersigned owner, or agent of the owner of the pet identified above, certify that I am eighteen years of age or over and authorize the veterinarian(s) at this practice to perform the above procedure(s). I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction: - The reasonable medical and/or surgical treatment options for my pet. - Sufficient details of the procedures to understand what will be performed. - How fully my pet will recover and how long it will take. - The most common and serious complications. - The length and type of the follow-up care and home restraint required. - An estimate of the fees for all services. (You can call at any time for an estimate) While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. I also understand that my pet’s medical condition may change for better or worse and the attending veterinarian(s) may add or change treatments to fit the needs of my pet’s care if it falls within the guidelines of the estimate that was provided to me. I assume financial responsibility for the services rendered and provide payment via cash, credit card (not American Express), or check at the time my pet is discharged from the hospital. Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency drugs, or other heroic interventions, I request the veterinarian(s) at this hospital pursue such medical care. Having requested such emergency procedures, I agree to be held responsible for any and all additional charges that may be necessary and to pay for the services performed while staff members pursue treatment and try to reach me for further directions. Regardless of my pet’s survival, I agree to pay this fee in addition to the other fees already identified by the practice and agreed upon by me. Signature * *This is your electronic signature. First Name Last Name Must be 18 years of age; In the event my pet is hospitalized beyond the first day at this facility, I understand that veterinary care during nighttime hours is provided at the discretion of the attending veterinarian, who is not present at the facility from midnight to 8 am. I am aware that there are other emergency facilities that have a veterinarian present at all times and have the option to transfer to one of these facilities. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made. I have read and understand the nature of the above procedures and give my consent to proceed. Thank you!
