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Client Form - Surgery Consent Form

Client Information

Address

Patient Information

Is your pet spayed/neutered?

Anesthesia / Sedation / Procedure / Surgical Consent
05/18/2022

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 surgical procedure(s):

Hidden
Consent Type

Abdominal Explore

Achilles Tendon Repair Followed By Placement of an External Skeletal Fixator (Esf) or Calcaneotibial Screw and/or Splinted Bandage for External Protection of the Achilles Tendon

Anal Sacculectomy

Oral/Laryngeal Exam, Staphylectomy (Shortening of the Soft Palate), Rhinoplasty (Widening of the Nares), and +/- Excision of Laryngeal Saccules If Warranted.

Bone Biopsy

Extracapsular Lateral Suture & Patella Luxation Stabilization

Cesarean Section and Ovariohysterectomy

Closed Coxofemoral (Hip) Reduction

Head CT Scan (+/- with contrast)

Cystotomy For Removal of Urethral and Urinary Bladder Stones and Scrotal Urethrostomy

Cystotomy For Removal of Urethral and Urinary Bladder Stones

stifle explore

+/- primary repair of medial and/or lateral collateral ligament, +/- prosthetic ligament (+/- using bone tunnels, Kirschner wires, or bone screws and washers). +/- removal of torn piece of meniscus, +/- extracapsular lateral suture placement, +/- placement of an external skeletal fixator, +/- placement of a splinted bandage.

Digit Amputation

Enucleation

Extracapsular Lateral Suture & Patella Luxation Stabilization

Extracapsular Lateral Suture

FHO

Fracture

Abdominal Explore, Cholecystectomy (Removal Of Gallbladder), +/- Duodenotomy (Incision Into the Small Intestine) to Evaluate For Patency of Common Bile Duct, and Liver Biopsy.

Gastropexy

Abdominal Explore and Hiatal Hernia Repair

Removal of Bone Plate and Bone Screws

Ligament Repair or Prosthetic Ligament

Limb Amputation

Abdominal Explore, Multiple Liver Biopsies (For Submission For Histopathology, Immunohistochemistry Stains, and Copper Quantification), and Culture (Bile and Liver).

Abdominal Explore, Liver Mass Removal Via a Liver Lobectomy, and +/- Additional Liver or Other Tissue Biopsies If Warranted.

Removal of the Mammary Mass with the Associated Mammary Glands

Orchiectomy (Castration)

Ovariohysterectomy

Pantarsal Arthrodesis

Patella Luxation Stabilization

Abdominal Explore and Repair of PPDH (with Suture, Pericardium, or Prosthetic Mesh).

Abdominal Explore, Placement of an Ameroid Ring Constrictor On the Portosytemic Shunting Vessel, and Liver Biopsy.

Perineal urethrostomy and +/- cystotomy for removal of cystic calculi if warranted.

SDF Luxation Stabilization with Heavy Duty Suture Followed by Placement of a Splinted Bandage.

Sedation For Diagnostic Work-Up

ABDOMINAL EXPLORE, INTESTINAL RESECTION AND ANASTOMOSIS, CULTURE, AND PLACEMENT OF A TEMPORARY JACKSON PRATT ABDOMINAL DRAIN.

Removal of the Mandibular and Sublingual Salivary Glands and Associated Portion of the Duct.

Mass Removal

Abdominal Explore, Splenectomy and Liver Biopsy

Tibial Plateau Leveling Osteotomy (TPLO) or Tibial Tuberosity Advancement (TTA) & Patella Luxation Stabilization

Tibial Plateau Leveling Osteotomy (TPLO) or Tibial Tuberosity Advancement (TTA)

Resection of Prolapsed Urethral Tissue and Castration

Wound Closure

I also authorize the use of appropriate sedatives and/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. Additional diagnostics and supportive care measures may also be recommended or completed along with this procedure.

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 understand that the following are, but are not limited to, possible risks associated with the procedure and/or current diagnosis:

  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding potentially resulting in the need for a blood transfusion
  • Negative explore
  • Recurrence or progression of clinical symptoms
  • Need for additional treatment
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding
  • Breakdown of Achilles tendon repair
  • Prolonged healing of Achilles tendon
  • Implant failure (pin breakage or loosening, bone screw breakage or loosening)
  • Implant or bone infection (osteomyelitis)
  • Bone fracture
  • Need for revision surgery
  • Persistent or recurrent lameness
  • Progressive arthritis
  • Bandage sores
  • Decreased range-of-motion of the tarsus (ankle joint)
  • Need for physical rehabilitation
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding potentially resulting in the need for a blood transfusion
  • Temporary or permanent fecal incontinence
  • Straining to defecate
  • Incomplete resection and/or an aggressive form of cancer requiring need foradjunctive therapy (i.e. radiation therapy and/or chemotherapy)
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding
  • Need for oxygen therapy
  • Need for temporary tracheostomy tube
  • Continued regurgitation/vomiting
  • Aspiration pneumonia (potentially requiring prolonged hospitalization and treatment)
  • Continued hiatal hernia requiring future surgical treatment
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding
  • Implant or bone infection (osteomyelitis)
  • Bone fracture
  • Persistent or recurrent lameness
  • Non-diagnostic histopathology (biopsy) results
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding
  • Implant failure (stretching or loosening of suture and +/-pin migration or breakage if applicable)
  • Implant or bone infection (osteomyelitis)
  • Kneecap reluxation
  • Bone fracture
  • Meniscal tear requiring additional surgery
  • Persistent or recurrent lameness
  • Progressive arthritis
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding potentially resulting in the need for a blood transfusion
  • Non-viable puppies
  • Septic abdomen
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Reluxation of the hip
  • Need for femoral head and neck ostectomy (FHO)
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Reaction to the contrast including renal failure and or acute death
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding, especially from the new scrotal urethrostomy site, requiring prolonged hospitalization
  • Contracture of the scrotal urethrostomy site
  • Increased risk of urinary tract infection due to the new scrotal urethrostomy site
  • Recurrence of stones
  • Uroabdomen (leaking of urine into the abdominal cavity)
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding
  • Recurrence of stones
  • Urinary tract infection requiring medical management
  • Uroabdomen (leaking of urine into the abdominal cavity)
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding
  • Implant failure (suture stretching or breakage, bone screw loosening and/or breakage, backing out of Kirschner wire/external skeletal fixator pins and/or breakage)
  • Implant or bone infection (osteomyelitis)
  • Persistent lameness
  • Progressive arthritis
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding potentially resulting in the need for a blood transfusion
  • Blindness to the contralateral eye due to optic nerve damage
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding
  • Implant failure (pin migration, suture stretching or breakage)
  • Implant or bone infection (osteomyelitis)
  • Kneecap reluxation
  • Meniscal tear requiring additional surgery
  • Persistent lameness
  • Progressive arthritis
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding
  • Implant failure (suture stretching or breakage)
  • Implant or bone infection (osteomyelitis)
  • Meniscal tear requiring additional surgery
  • Persistent lameness
  • Progressive arthritis
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding
  • Temporary or permanent nerve damage
  • Persistent or recurrent lameness
  • Progressive arthritis
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding
  • Delayed bone healing or non-healing bone (non-union)
  • Malunion bone healing (malaligment)
  • Implant failure (pin migration, screw pullout, plate breakage or failure)
  • Implant or bone infection (osteomyelitis)
  • Bone fracture
  • Persistent or recurrent lameness
  • Progressive arthritis
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding potentially resulting in the need for a blood transfusion
  • Gallbladder rupture
  • Dehiscence (opening up) of the ligated (tied off) cystic duct causing bile leakage and need for additional surgery
  • Bile peritonitis (inflammation of the abdominal cavity due to bile)
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Decreased gastric motility resulting in vomiting/regurgitation
  • Need for revision or intential breakdown of gastropexy site
  • Abdominal skin incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding potentially resulting in the need for a blood transfusion
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Vomiting/regurgitation
  • Aspiration pneumonia
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding potentially resulting in the need for a blood transfusion
  • Temporary or permanent damage to the vagus nerve
  • Recurrence of hiatal hernia
  • Persistent vomiting/regurgitation requiring long-term medical management
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding
  • Delayed bone healing or non-healing bone (non-union)
  • Implant or bone infection (osteomyelitis)
  • Bone fracture
  • Persistent or recurrent lameness
  • Progressive arthritis
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding
  • Implant failure (suture loosening or breakage)
  • Decreased joint range-of-motion
  • Progressive arthritis
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding potentially resulting in the need for a blood transfusion
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding potentially resulting in the need for a blood transfusion
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Hemorrhage (can be life threatening) potentially resulting in the need for a blood transfusion
  • Incomplete resection of the tumor
  • Need for adjunctive therapy (i.e. chemotherapy)
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding
  • Incomplete resection and/or an aggressive form of cancer requiring need for adjunctive therapy (i.e. radiation therapy and/or chemotherapy)
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Scrotal hematoma
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding potentially resulting in the need for a blood transfusion
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding
  • Lack of fusion of the joint
  • Implant failure (screw pullout, plate breakage or failure)
  • Implant or bone infection (osteomyelitis)
  • Bone fracture
  • Persistent or recurrent lameness
  • Progressive arthritis
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding
  • Implant failure (pin migration)
  • Implant or bone infection (osteomyelitis)
  • Kneecap reluxation
  • Persistent lameness
  • Progressive arthritis
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding potentially resulting in the need for a blood transfusion Dehiscence (breakdown) or PPDH repair
  • Need for removal of one or more organs due to adhesions or loss of domain
  • Acute renal failure
  • General anesthetic risks including, but not limited to, hypotension [low blood pressure] and hypothermia [decreased temperature]
  • Life-threatening cardiorespiratory arrest (death)
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding potentially resulting in the need for a blood transfusion
  • Tearing of the shunting vessel requiring ligation with suture
  • Persistent shunting potentially requiring additional surgery or long-term medical management
  • Formation of new shunting vessels
  • Portosytemic hypertension
  • Underlying liver disease requiring additional medical management
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding, especially from the new perineal urethrostomy site.
  • Contracture of the perineal urethrostomy site
  • Increased risk of long-term urinary tract infection(s)due to the new perineal urethrostomy site
  • Recurrence of stones
  • Uroabdomen (leaking of urine into the abdominal cavity)
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding
  • Implant failure (suture loosening or breakage)
  • SDF reluxation
  • Persistent lameness
  • Progressive arthritis
  • acute cardiorespiratory arrest (death)
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding potentially resulting in the need for a blood transfusion
  • Reoccurrence of intestinal dehiscence
  • Pancreatitis
  • Disseminated Intravascular coagulation
  • Multiple organ failure
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding
  • Recurrence of mucocele
  • Need for additional treatment
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding potentially resulting in the need for a blood transfusion
  • Incomplete resection and/or an aggressive form of cancer requiring need for adjunctive therapy (i.e. radiation therapy and/or chemotherapy)
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Cardiac arrythmia(s) that do not resolve on own thus requiring medical management
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding potentially resulting in the need for a blood transfusion
  • Need for adjunctive treatment (i.e. chemotherapy)
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding
  • Delayed bone healing or non-healing bone (non-union)
  • Implant failure (pin migration, screw pullout, plate breakage or failure)
  • Implant or bone infection (osteomyelitis)
  • Kneecap reluxation
  • Bone fracture
  • Meniscal tear requiring additional surgery
  • Persistent or recurrent lameness
  • Progressive arthritis
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding
  • Delayed bone healing or non-healing bone (non-union)
  • Implant failure (pin migration, screw pullout, plate breakage or failure)
  • Implant or bone infection (osteomyelitis)
  • Bone fracture
  • Meniscal tear requiring additional surgery
  • Persistent or recurrent lameness
  • Progressive arthritis
  • General anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional infection
  • Incisional swelling (seroma)
  • Incisional dehiscence (breakdown)
  • Bleeding
  • Recurrence of urethral prolapse
  • General anesthetic risks
  • General sedative/anesthetic risks
  • Life-threatening cardiorespiratory arrest
  • Incisional breakdown and separation (dehiscence)
  • Incisional infection
  • Incisional swelling (seroma)
  • Bleeding

*THIS PROCEDURE IS FOR DIAGNOSTIC PURPOSES ONLY, IT IS NOT A TREATMENT*

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 surgery, procedure or sedation/anesthesia is performed, such as follow up radiographs, bandage changes, 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 understand that the estimate presented to me for the procedure/sedation/anesthesia is for a procedure without significant complication only.

I have read and fully understand the potential complications, terms, and conditions.

Location Confirmation(Required)
Procedure Confirmation(Required)
Did the patient eat after 10PM last evening?
Current medications, dosing, and quantity remaining

Cardiopulmonary Resuscitation (CPR) Directive

I 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 ...
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What Pet Owners are Saying

Testimonial – John, CO

This area of town is growing rapidly and the addition of this top notch facility can only enhance the quality of veterinary care in the area. With Dr. Rector and Tammi providing the best in medicine and customer service, this specialty hospital will be a huge success and source of quality care for the community.

John, CO
Testimonial – Laura, CO

Amazing staff and experience. They are very caring and thoughtful. Not to mention they saved my dog! Highly recommend!

Laura, CO
Testimonial – Vickie, CO

Dr. Rector is very compassionate and helped guide us to make the best decisions for Falkor. If it were not for her and her amazing and dedicated staff, Falkor would not have fully recovered. We are so grateful for the care provided!

Vickie, CO
Testimonial – Jason, CO

I have always had a great experience when bringing my yellow lab Biscuit to Dr. Rector’s hospital. My dog Biscuit likes to eat things she shouldn’t, and Dr. Rector has been very quick and thorough when treating her in the past. She explains everything and provides us with excellent care. We don’t think twice about taking Biscuit to see Dr. Rector, she takes good care of our family!

Jason, CO

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Emergency Services
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Veterinary Specialists of the Rockies

774 Maleta Lane (One block North of Founders Parkway)

Castle Rock, CO 80108

Appointments: 303.660.1027

 

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