Surgical Consentplease complete the form belowCLIENT INFORMATION First Name (required) Last Name (required) Address (required) City (required) Zip Code (required) Email (required) Phone (required) My pet is having the following procedure today PET INFORMATION Name (required) Breed (required) Age (required) Species CanineFelineOther Is your petHaving any vomiting? NoYesHaving any diarrhea? NoYesHaving any coughing? NoYesHaving any sneezing? NoYesHave you noted that your pet is experiencing weight loss? NoYesIs your pet experiencing any pain? NoYesPet's appetite? IncreasedDecreasedNo changePet's drinking? IncreasedDecreasedNo changePet's urination? IncreasedDecreasedNo changeMEDICATION/SUPPLEMENTS If your pet is on any medications, please list drug names, dose, and how often they are administered, or write none. (required) For Spays and Neuters only: Did you administer preoperative Cerenia (anti nausea medication)? If so, please list date and time. NoYes If your pet is taking any supplements, please list supplement names, and how often they are taken, or write none. (required) Does your pet have any known medication allergies? NoYes Does your pet have any previous medical conditions? If your pet needs medications to go home after their procedure, do you prefer TabletsLiquidLong lasting medications administered in hospital before dischargeThe last time my pet ate was: (required) CONSENT At Folsom Ranch Veterinary Hospital we do everything we can to keep your pet as safe and comfortable as possible. Unfortunately, unforeseen complications from surgery or anesthesia may arise. I hereby authorize anesthesia-surgery for my pet. I understand that anesthesia and surgery carry inherent risks and complications may arise including infection, blood loss and rarely loss of life. I understand and I assume all risks and will not hold Folsom Ranch Veterinary Hospital, the Veterinarians or any staff member liable for any complications should they arise. I understand that I am responsible for all costs involved and payment is required for all services at the time they are rendered.In the unfortunate event that your pet experienced a cardiopulmonary arrest (his-her heart stops or he/she stops breathing on their own), we at FRVH need to know you and your family’s wishes on how you would like us to respond. Some families choose for us to pursue CPR (cardiopulmonary resuscitation) in an attempt to re-establish your pet’s heartbeat. Due to many understandable circumstances, some families ask that CPR is not pursued, designating their pet at DNR (do not resuscitate). Please know that we support and respect your family’s decision regardless of your reasoning. Please make your selection below:I wish to select CPR, including chest compressions and manual ventilation. I acknowledge the risks associated with CPR and consent to the initial resuscitation charges of $500-1000, knowing this total may substantially increase if extensive intervention is needed to recover my pet.I wish to select DNR, acknowledging that no life-saving measures will be deployed should my pet’s heartbeat or breathing capabilities stop.I consent to receive SMS text messages from Folsom Ranch Veterinary Hospital. Message & data rates may apply. Reply STOP to opt out.I am over 18 years of age and am the authorized owner and-or guardian for the aforementioned patient. I authorize Folsom Ranch Veterinary Hospital and Urgent Care (FRVH) to perform treatment/procedure(s) on my pet as recommended by FRVH's Veterinarians and employees. I was informed of the reasons for the treatment/procedure(s), along with the expected benefits and risks involved. I confirm that by signing below, I understand the inheritable and sometimes unforeseen risks associated with veterinary care and release all liability, without exceptions, from Folsom Ranch Veterinary Hospital (FRVH) while treating my pet. I understand that payment is required for all services at the time they are rendered unless prior arrangements have been made with hospital management. I understand that deposits may be required prior to certain procedures. In the event that a refund is due and the original payment is a credit card, the refund will be posted against the original credit card. I also authorize FRVH to use pictures of my pet(s) for learning or marketing purposes. Consent will apply to all future pets added to this account unless and until I provide a written revocation of that consent.SIGN BELOW
