Surgical & Anesthesia Consent Form

Bridger Veterinary Hospital

3104 Green Meadow Drive

Helena, MT 59602

[email protected]

406-443-5874

CLIENT NAME:

PATIENT NAME

Please list items left with your pet:

List all medication(s) your pet is on: Last doses give (time):

I authorize Bridger Veterinary Hospital to perform the following procedure(s) on my pet:

Spay/Neuter Surgery* Mass Removal Dental Cleaning

Other:

PLEASE NOTE: Pets having surgery and/or an IV catheter MAY have fur shaved at the corresponding sites.

*If your pet is getting spayed and is currently showing signs of being in heat, please contact us immediately as we may elect to postpone the surgery for the safety of your pet.

COMPLETE FOR DENTAL CLEANINGS ONLY

Please initial ONE of the following:

I authorize Bridger Veterinary Hospital to perform any recommended dental x-rays, extractions, minor oral, or non-oral

surgery not list on estimate WITHOUT contacting me first, with NO LIMIT to the dollar amount above my estimate.

I authorize Bridger Veterinary Hospital to perform any recommended dental x-rays, extractions, minor oral, or

non-oral surgery WITHOUT contacting me first, up to an amount of $

Please contact me to discuss additional recommended procedures, and if I am unable to be reached at the contact info

provided, please do NOT perform any additional procedure that has not been previously discussed. I understand that this may

result in the need for a second anesthetic procedure with associated costs.

Pre-Surgical Bloodwork:

Your pet's risk of complications during and after anesthesia and surgery is tremendously greater if there is preexisting organ disease, malfunction, or failure.

We strongly encourage bloodwork before anesthesia and surgery to help rule out these problems or identify them and devise an alternative treatment plan to

meet your pet's unique needs. These blood panels provide immensely valuable information.

Please initial ONE of the following:

I authorize pre-anesthetic bloodwork based on doctor's recommendations, $160+.

I DECLINE the recommended pre-anesthetic tests and request that you proceed with anesthesia. I understand that a medical

condition may exist which would be impossible to identify during a physical exam alone. I understand that my pet's health

could be at risk if such a condition goes undetected when my pet is placed under anesthesia.

Anesthesia Support (IV Catheter):

An IV catheter and fluids are recommended to maintain your pet's blood pressure and decrease the risks of organ damage from decreased blood pressure,

prevent dehydration, and to aid in recovery, as well as to provide a life-line in the event of an emergency.

I DECLINE IV fluids for my pet and understand the potential risks.

Please initial ONE of the following:

I authorize BVH to place an IV catheter for my pets procedure. I understand that my pets age, breed, and/or medical conditions warrants

further supporting my animal during this procedure. I understand that BVH has a policy that any animal over 10 years of age is required

to have IV fluids during this procedure, $110.00.

Resuscitation Orders:

In the event my pet's heart and/or breathing stop (cardiopulmonary arrest), resuscitation efforts according to the advanced directive below will be undertaken

by the doctor(s) and/or staff of BVH. We will perform our best to resuscitate your pet, however CPR success rates of ~13-15%. Furthermore, I understand

that I will be responsible for any costs incurred in performing these measures.

I DECLINE medical intervention to save my pet.

I authorize medical intervention to save my pet.

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Please initial ONE of the following:

DATE