Surgery Authorization Form Surgery Authorization Form Pre Surgical InformationYour pet has been scheduled for surgery. In order to make the anesthetic and surgery as safe as possible, please follow these instructions:Take up your pet’s food at 7 PM the night before surgery.Allow your pet to have water all night and pick it up at 7 AM on the day of surgery.Do not feed your pet breakfast on the day of surgery.Please be sure to bring any proof of vaccinations within the past year, if we have not administered the vaccines here.If your pet is taking chronic medications, please consult with our veterinarians before surgery for instructions as to which medications should or should not be given prior to surgery.If you have an Elizabethan collar for your pet, you may bring it with you at the time of drop off so that we will not have to dispense one for your pet to protect the wound. Anesthesia:We take pains to make certain that every pet is fit for anesthesia prior to surgery. Each pet is examined prior to surgery and in most instances, bloodwork will be performed to make certain there are no organ system problems which might make anesthesia more risky.Your pet will be sedated mildly upon arrival to reduce their stress levels.Pain relief medication will be administered prior to surgery to minimize any post-operative pain.If indicated, an IV catheter will be placed to ensure access to the circulatory system before and during surgery.We anesthetize most pets with a fast-acting induction agent; propofol, to allow us to place a breathing tube in the trachea. Once it is placed, we continue the anesthetic with isoflurane or sevoflurane gas, (the same anesthetics that you or I would receive) which gives us the greatest control and safety margin of any agents.Once safely under anesthesia, we monitor your pets with sophisticated electronic machines along with hands-on observation by our technicians to ensure their safety. After Surgery:Once your pet is awake from anesthesia, our staff continuously monitor them until they can walk on their own and their body temperature returns to normal.We evaluate their post-op pain scores and administer additional pain medication if needed to make them comfortable.If applicable, an Elizabethan collar is placed around the neck to protect the wound from the pet’s chewing.Your pet is returned to his/her cage with comfortable bedding until it is time for discharge.If your pet’s surgery is complicated or there are other medical issues to be managed, he/she may stay in the hospital until they are resolved. Could not connect to the reCAPTCHA service. Please check your internet connection and reload to get a reCAPTCHA challenge.Name First Last PhoneEmail Do you prefer electronic communication?*YesNoBest time to contact:* : HH MM AMPM Consent* I do hereby give my permission for Alta Rancho Pet Hospital to perform the following procedure(s) on my pet.Pet's Name*Species*Breed*Sex*MaleMale - neuteredFemaleFemale - spayedAge*Weight*While my pet is anesthetized, I would like the following procedure(s) performed in addition to those listed above: Nail Trim Ear Flush Anal Gland Expression Dental Cleaning Hip Dysplasia X-rays Stool Exam Microchip I.D. Implant OtherPRE-ADMISSION REQUIREMENTS: For the safety of your pet and all of our patients, all pets admitted for surgery or hospitalization are required to have proof of current vaccination administered by a veterinarian. If proof is not available, vaccinations will be administered at our normal fees. If external parasites are found on your pet, eradication treatment will be necessary at our normal fees.Initial*DENTISTRY CHARGES: I understand that during the dentistry, one or more teeth may need to extracted due to irreparable damage. I further understand that there will additional fees incurred, ranging from $38.00 to $150.00 per tooth depending on the number of roots and difficulty in the extraction. Fees for pain management will be charged with extractions too. I agree to pay these fees in addition to those quoted in the original estimate.Consent*I authorize extraction(s) of diseased teethI authorize extraction(s) of diseased teeth up to a specific dollar amount (you will enter this below), if more, please call me.I DO NOT authorize any extractions of any teeth regardless of their condition.STERILIZATION CHARGES: In the event that your pet has recently been in heat, is currently in heat, or is pregnant, there will be additional charges based on the increased surgical difficulty, time involved as well as additional supportive measures. These charges vary greatly and you should discuss them with our staff prior to signing this form.GENERAL WAIVER: We take great care in ensuring your pet’s safety while under our care and particularly while under anesthesia. However, there still remains a small chance of anesthetic related death whenever a patient is anesthetized. I acknowledge that the nature of the procedures to be performed, the risks and/or complications involved including those risks posed by anesthesia, and the fees incurred for such have been adequately explained to me. I further acknowledge that no guarantee regarding the outcome of any procedure has been expressed or implied by ARPH or any of its agents.Inital*FINANCIAL RESPONSIBILITY:I understand that the estimate of charges that has been provided to me by Alta Rancho Pet & Bird Hospital and/or its agents is a best approximation of the cost of services and that the final bill may vary above or below the estimate. I further understand that if the actual charges exceed the estimated charges by more than fifteen (15%) percent, Alta Rancho Pet & Bird Hospital will make every attempt to contact me for authorization prior to performing additional services unless such procedures are essential, life-saving measures. I agree that failure to contact me does not relieve me from responsibility for these fees. I accept full financial responsibility for services rendered including charges which may arise due to unforeseen medical or surgical complications incurred in the treatment of my pet as well as the cost of follow-up visits and procedures (i.e. additional x-rays, bandages changes etc.).FOLLOW UP FEES: I understand that if a surgery is performed, one post-operative visit is included in the cost of today's procedure. This visit will cover the cost of drain removal, suture removal and/or bandage REMOVAL ONLY. If additional services are required, including but not limited to, ADDITIONAL BANDAGING, injections, medication, diagnostic tests, physical examinations and x-rays, I understand that they will be provided according to the normal fee schedule.Initial*PAYMENT: Deposits: I understand that a deposit of at least 50% of the estimated fees are due upon hospitalization and that the balance of payment is due and payable prior to the release of my pet. I understand that payment for services is due in the form of cash, Care Credi, money order, Debit cards Traveler's Check, Visa, Master Card, or American Express, or Discover Card.LEGALITY: I understand that this is a legally binding contract. I acknowledge that I have read and understood the contents herein and that I have signed this document of my own free will.SignatureAnesthetic Comfort and Safety Options: At Alta Rancho Pet & Bird Hospital, we are very concerned about the comfort and safety of your pets. Anesthetic procedures pose certain risks to all animals (including humans) and our goal is to minimize those risks at all times. There are a number of services that we can provide that help achieve these goals. They are listed in the table below. Some or all of these services may have already been included on your estimate by the doctor based on the needs and risk factors associated with your pet. All of these services are important but they do have attendant costs associated with them, which may not fit into everyone’s budget. Therefore we have made them available as options. To help promote the safest anesthetic possible, we offer a ten percent (10%) discount on 3 to 4 services and fifteen (15%) discount on 5 or 6 services selected. Please select the services which you would like us to perform on your pet and our reception staff will let you know the actual cost for your pet (some costs vary with the weight of your pet).Pre-Op Blood Testing Blood tests allow us to detect underlying metabolic problems such as diabetes, liver or kidney disease, electrolyte abnormalities, anemia etc. which may make anesthesia more risky. Fees differ based on the age of the pet. A limited panel is typically run on pets 5 years and under while a more comprehensive panel is run on older animals.Pre-Op Electrocardiogram Electrocardiograms tell us of any underlying heart problems.I.V. Catheter and Fluids An I.V. catheter and fluids helps maintain the blood pressure and protect the kidneys and internal organs from the effects of anesthesia. Having an open port to the blood system allows us rapid access for emergency drug administration. Propofol InductionPropofol is one of the safest drugs to begin anesthesia with. It has minimal side effects and allows the pets to wake up “hangover” free.Pain Relief InjectionLong acting pain relief injections help minimize your pet’s suffering and lead to faster recovery. Pain Medication to go homeEach pet experiences pain in different ways. Studies show that post operative pain medication can substantially improve recovery. This is an option for all procedures.Laser Surgery Lasers reduce pain and inflammation and lead to more comfortable recovery (see the display at our front counter for more details).Would you like us to perform any of the above services?* Pre Op Blood Testing - $42.00 to $82.00 Pre-Op Electrocardiogram - $37.50 I.V. Catheter and Fluids - $57.75 Propofol Induction - $41.50 to $65.00 Pain Relief Injection - $29.50 to $40.50 Pain Medication to go home - $29.50 to $48.00 Laser Surgery - $53.00 No additional services - $0Consent* I accept financial responsibility for the costs of the services I have selected to be performed on my pet.Date Date Format: MM slash DD slash YYYY SignatureDownload a printable form here.