Anesthesia/Sedation/Procedure/Surgical Consent Client InformationClient Name Address Street Address City State / Province / Region ZIP / Postal Code Phone Patient InformationPatient Name Species Breed Sex Color Weight Is your pet spayed/neutered? Yes I am the owner/authorized agent of this animal and am 18 years of age or older. I hereby authorize the staff of Veterinary Specialists of the Rockies or its contracted agents, including, but not limited to Trek Veterinary Surgery or MoVeS Managed Services, Inc., to perform the following procedure(s), endoscopy, surgery or anesthesia/sedation:HiddenConsent Type ESOPHAGEAL FOREIGN BODY RETRIEVAL GASTRIC FOREIGN BODY RETRIEVAL GASTRODUODENOSCOPY/COLONOSCOPY CYSTOSCOPY RHINOSCOPY CT SCAN BRONCHOSCOPY BONE MARROW Esophageal Foreign Body RetrievalGastric Foreign Body RetrievalGastroduodenoscopy/Colonoscopy Cystoscopy Rhinoscopy CT Scan Bronchoscopy Bone MarrowI also authorize the use of appropriate sedatives or inhalant/injectable anesthetic medications as needed for sedation or anesthesia of my pet. I also recognize that other medications such as antibiotics and analgesics may be necessary during and after the procedure for my pet and I will continue these medications at home if directed by my pet’s attending veterinarian. I understand that while performing the procedure stated above, unforeseen conditions may arise which could necessitate continued care or an altered (or additional) operation/procedure plan. I hereby authorize the procedures required as deemed appropriate by the veterinarian’s professional judgment. I have been informed of the procedure and any possible risks that are involved with this procedure, anesthesia and/or sedation. I have reviewed the addendum below for a list of specific risks applicable to the procedure my pet is having performed. I also understand that there is an inherent risk with anesthesia and/or sedation and complications may occur, including death. You are encouraged to discuss any concerns regarding these risks with the attending veterinarian before the procedure(s) is/are initiated. While I accept that all procedures will be performed to the best of the abilities of the staff and contracted agents at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the endoscopy, surgery, procedure or sedation/anesthesia is performed, such as follow up radiographs, recheck physical exams and additional surgery due to post-operative complications. Failure to comply with post-operative instructions is more likely to lead to post-operative complications and delayed healing. A complete physical exam will be performed on your pet prior to the surgical procedure if it has been longer than 30 days since the last exam. However, this may not identify all systemic or metabolic problems. Your pet will have a pre-anesthetic blood panel to evaluate major organ functions prior to anesthesia, however this does not fully eliminate the risk of sedation or anesthesia. I have read and fully understand the terms and conditions.Phone numbers at which owner can be reached today and tomorrow Did the patient eat after 10PM last evening? Yes No Cardiopulmonary Resuscitation (CPR) DirectiveI understand Veterinary Specialists of the Rockies (VSR) requires a CPR status prior to the start of any and all procedures so immediate action can take place in the event of cardiopulmonary arrest during, before, or after anesthesia or anytime in our care. I acknowledge that the attending veterinarian or staff members of VSR will make every effort to contact me regarding treatment in the case of this unforeseen event. The starting cost of CPR is approximately $400.I am the owner / agent of this pet and ... DO AUTHORIZE CPR efforts for my pet DO NOT AUTHORIZE CPR (DNR) efforts at this time Date MM slash DD slash YYYY ADDENDUM: COMPLICATIONS ASSOCIATED WITH ANESTHESIA AND THE PROCEDURE ANESTHESIA RELATED Potential complications include: low heart rate, irregular heart rhythms, low blood pressure, low temperature, organ damage, tracheitis (inflammation of the trachea causing a cough), neurological deficits, and rarely sudden death.ESOPHAGEAL FOREIGN BODY RETRIEVAL Potential complications include: temporary bloating and flatulence are most common, mild bleeding, rarely with chronic foreign bodies or severe disease perforation (tearing) of the esophagus is possible. Failure to remove the foreign material endoscopically is possible, in which case surgery would be indicated.GASTRIC FOREIGN BODY RETRIEVAL Potential complications include: temporary bloating and flatulence are most common; mild bleeding; rarely with severe disease (cancer, severe ulceration), perforation (tearing) of the stomach or intestines necessitating surgical intervention is possible. Failure to remove the foreign material endoscopically is possible, in which case surgery would be indicated.GASTRODUODENOSCOPY/COLONOSCOPYPotential complications include: temporary bloating and flatulence are most common; mild bleeding; rarely with severe disease (cancer, severe ulceration), perforation (tearing of the intestines) necessitating surgical intervention is possible; Torsion, or twisting of the intestines has rarely been reported and would necessitate surgical intervention.CYSTOSCOPYPotential complications include: Bleeding, irritation and damage to the inside of the lower urinary tract (bladder, urethra) that can cause temporary worsening of clinical signs (small frequent urinations, straining to urinate); with severe disease (most often cancer), perforation, or tearing of the urethra and/or bladder is possible.RHINOSCOPYPotential complications include: Bleeding, irritation and damage to the inside of the nose that can cause temporary worsening of clinical signs, if the cribiform plate (bone between the brain and nose) is not intact, brain damage is possible.CT SCANPotential complications include: General anesthetic risks, life-threatening cardiorespiratory arrest, reaction to the contrast including renal failure or acute death.BRONCHOSCOPYPotential complications include: Bleeding, irritation and damage to the inside of the trachea that can cause temporary worsening of clinical signs, compromised breathing that can increase the risk of anesthetic complications.BONE MARROW BIOPSYPotential complications include: temporary discomfort that can be controlled by oral pain medications is most common; however, more severe pain is possible. With underlying bone disease, fracture of the bone may occur.Owner/Agent Signature(Required)PhoneThis field is for validation purposes and should be left unchanged. Δ
