Mass Removal Surgery Consent Form

Pet Name:*

Species:*

Breed:*

Sex:*

Female Intact

Female Spayed

Male Intact

Male Neutered

Age / DoB:*

As the owner of this pet, I understand that during the performance of the dental procedure(s) or surgical operation(s), unforeseen conditions or problems may become evident that necessitate an extension of the procedure. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary of the exercise of the veterinarian’s professional judgment.

I also authorize the use of appropriate anesthetics and other medications and I understand that hospital personnel will be employed as deemed appropriate by the veterinarian. I have been advised about the nature of the procedure(s) and the risks involved. I realize that results cannot be guaranteed.

Please check all that you agree to:*

Food has been withheld since 9:00 PM last night and water has been withheld since 7:00 AM today.

I understand that my pet may have its leg shaved so that a catheter can be set so that fluids may be given during the anesthetic procedure. This keeps the blood pressure up and blood flowing to the vital organs, replenishes fluids, and also provides an injection port for emergency drugs should they be needed.

For the safety of all our pets as well as our personnel, all pets must be current on rabies vaccinations and dogs must be up to date on Bordatella (“kennel cough”) vaccinations. If they are not, these will be administered while they are hospitalized.

To the best of your knowledge, has your pet ever had seizures or convulsions?*

Yes

No

Other than heartworm and/or flea control, is currently on any medication?*

Yes

No

If yes, please list the medications and how much/how often it is given.

Pre-Anesthetic Blood Testing & EKG Consent
Our greatest concern is the well-being of your pet. A pre-anesthetic blood profile and EKG are needed to evaluate health issues that could increase anesthetic risks and alert the doctor to the presence of dehydration, anemia, infection, diabetes, and/or heart/kidney/liver disease that could complicate the procedure. In addition to assessing anesthetic risks, these tests will also serve as a baseline for future evaluations. The cost for the complete blood count, blood chemistry profile, and EKG is $199.50.*

I accept the pre-anesthetic blood work and EKG required by the veterinarian.

Microchip Placement
We suggest that you consider protecting your emotional and economic investment. A very effective means of increasing your chances of finding your pet should it ever become lost or stolen is by the implantation of a HomeAgain microchip. Many animal control facilities, veterinarians, and humane societies have scanners that could be used to identify your pet should it be taken to one of these facilities. Our staff can implant one today if you desire.

The cost for implantation is $49.50. This fee includes the initial setup fee (an $11 value) as well as the first year’s membership and the first year’s inclusion in the nationwide database.*

I accept HomeAgain microchip implantation for permanent identification.

I decline HomeAgain microchip implantation for permanent identification.

Extractions of Teeth if Needed (for dental procedures only)
As we explore and more closely examine your pet’s mouth under anesthesia, it may become evident that some of its teeth have severe problems. Options for treating such problems include root canals, gum grafting, and other procedures. There are veterinarians in our area who are dental specialists and will be able to perform the procedures more efficiently than our staff since they have the expertise and the equipment needed for such procedures. However, should you not wish to pursue such procedures, we will be glad to extract any teeth that appear to not be salvageable without the intervention of a specialist. We suggest these teeth be removed while your pet is already under anesthesia if you wish to have extractions performed.*

I request that no teeth be extracted.

I grant permission for any teeth that appear to not be salvageable without specialist intervention to be extracted while my pet is under general anesthesia. I understand that such extractions will be performed at an additional fee.

Submission of Tissues to Pathologist
We suggest that a pathologist evaluate practically all masses that we remove. The pathologist will take extremely thin sections (usually only 1 or 2 cell layers thick) of the tissue and look at them under a microscope. Based on the types of cells that are present, the pathologist can tell us such things as whether the mass is malignant, possible causes of the mass, if it appears that we left behind any residual tissue that needs removal, what if any expected side effects may be associated with the masses, and gives us information as to the management of your pet's mass.

There is an additional fee for submission of the mass(es) to a pathologist.
The lab biopsy fee is $155 for one mass, $229.50 for two masses, or $309.50 for three masses. We can provide an estimate for 4 or more masses upon request. Masses of Mammary Chains are $265. Masses requiring decalcification (such as digits & bone biopsies) may incur modest additional fees.

I request that the removed tissues be submitted to a pathologist for evaluation.

I request that tissues not be submitted to a pathologist for evaluation.