Owners Name *

First

Last

Phone where you can be reached today *

Email *

Patient's Name *

Referring Hospital *

Referring Veterinarian *

Procedure Date *

IF YOU ARE UNSURE WHICH PROCEDURE YOUR PET IS HAVING WITH MVS, PLEASE CHECK WITH YOUR REGULAR VETERINARY CLINIC TO ENSURE THE RIGHT CORRECT PROCEDURE IS LISTED AND DETAILS ABOUT THE SURGERY ARE AVAILABLE. ALTERNATIVELY YOU CAN CONTACT OUR OFFICE AT INFO@MIDWESTVETSURG.COM AND WE CAN PROVIDE WHICH PROCEDURE YOUR DOG IS SCHEDULED TO HAVE WITH US AT YOUR VETERINARY CLINIC.

Surgical Release Forms *

Anal Sacculectomy

Your pet has been diagnosed with anal gland problems that necessitate surgical removal of the anal sac. This can include abscesses, recurrent infections, or impactions. The underlying pathology associated with anal sac disease is often related to allergic disease. Often both glands are removed at the same time even if only one gland is affected to prevent future problems on the other side. However, unless the underlying cause is addressed, allergic conditions can also manifest in the ears and other areas of the skin. Although every effort is made to prevent or minimize complications, any surgery near the rectum has a higher complication rate than other areas of the body. Besides the obvious issue of fecal contamination that can lead to infection, pets frequently lick or scoot after surgery which can irritate the incision or prematurely tear out any sutures if they are utilized. Additionally, bowel movements can be affected due to postoperative discomfort, and many times your veterinarian may prescribe stool softeners for a short time until the surgical wound is healed. Previous surgery or infections can make removing the entire gland more difficult and increase the chance of draining tracts forming after surgery. The goal of surgery is to remove the entire sac and lining as well as the duct to prevent future problems. If any part of the gland is inadvertently left behind, it can secrete anal sac fluid under the skin which can lead to infection and more surgery. I consent to the selected surgical procedure(s). *

I have read and authorize

Procedure: *

Unilateral Anal Gland Excision
Bilateral Anal Gland Excision

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage, incisional complications (infection, dehiscence, seroma (fluid accumulation) formation), bruising and swelling, tenesmus (straining), perianal fistula formation, transient incontinence due to surgery site swelling and inflammation, and rarely permanent incontinence. Permanent incontinence may occur if removal of greater than 50% of the circumference of the anal sphincter is required. *

I have read and understand the risks.

Anal Sac Tumor Removal

Apocrine gland anal sac adenocarcinoma (AGASACA) are the most common type of anal sac tumors, and account for approximately 2% of all skin tumors. Other types of anal sac masses include adenomas and squamous cell carcinoma. Paraneoplastic hypercalcemia (elevated calcium) and metastasis (spread to other regions of the body, especially the sublumbar lymph nodes) are very common with AGASACA. Complete staging including bloodwork, thoracic radiographs, and abdominal ultrasound should be performed prior to surgery to fully evaluate for these changes and make the best surgical plan. If metastasis to the sublumbar lymph nodes is present, they should also be surgically excised, as removal of them has been shown to increase survival time. Radiation therapy is also recommended following surgery to further increase the median survival time. I consent to the selected surgical procedure(s). *

I have read and authorize

Procedure: *

Anal Gland Tumor Excision

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage (can be significant for sublumbar lymph node removal due to close association with large blood vessels), incisional complications (infection, dehiscence, seroma (fluid accumulation) formation), bruising and swelling, hypocalcemia, tenesmus (straining), tumor recurrence, perianal fistula formation, transient incontinence due to surgery site swelling and inflammation, and rarely permanent incontinence. Permanent incontinence may occur if removal of greater than 50% of the circumference of the anal sphincter is required. *

I have read and understand the risks.

Bone Biopsy

Your pet has been diagnosed with bone lesion that requires a biopsy and will be undergoing surgery to determine the cause of this lesion. The surgeon will carefully examine the entire region for any abnormalities and take a biopsy of the affected region during the procedure. It is important to identify the cause of the lesion to further direct your pet’s treatment recommendations. There are some instances when biopsy of the affected region does not yield an answer due sample representation. I consent to the selected surgical procedure(s). *

I have read and authorize

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage, exacerbation of lameness after biopsy and risk for fracture at the time of biopsy or post biopsy, incisional complications (infection, dehiscence, and seroma (fluid accumulation) formation). There is also the risk that a nondiagnostic sample will be obtained; this would require repeating the procedure or moving to an excisional biopsy. *

I have read and understand the risks.

Brachycephalic Airway Surgery

Your pet has been diagnosed with brachycephalic airway syndrome. Certain breeds of dogs and cats are prone to difficult, obstructive breathing because of the shape of their head, muzzle and throat. The most common dogs affected are the “brachycephalic” breeds. Brachycephalic means “short-headed.” Common examples of brachycephalic dog breeds include the English bulldog, French bulldog, Pug, Pekingese, and Boston terrier. These dogs have been bred to have relatively short muzzles and noses and, because of this, the throat and breathing passages in these dogs are frequently undersized or flattened. Persian cats also have a brachycephalic conformation. The main components of brachycephalic airway syndrome include stenotic nares (malformed nostrils that are narrow or collapse inward during inhalation, making it difficult for the dog to breathe through its nose), an elongated soft palate (the soft palate is too long so that the tip of it protrudes into the airway and interferes with movement of air into the lungs), everted laryngeal saccules (tissue within the airway, just in front of the vocal cords, is pulled into the trachea (windpipe) and partially obstructs airflow), and a hypoplastic trachea (a trachea (windpipe) with a small diameter). Some dogs with brachycephalic syndrome may also have a narrow trachea (windpipe), collapse of the larynx (the cartilages that open and close the upper airway), or paralysis of the laryngeal cartilages. Dogs with elongated soft palates generally have a history of noisy breathing, especially upon inspiration (breathing inward). Some dogs will retch or gag, especially while swallowing. Exercise intolerance, cyanosis (blue tongue and gums from lack of oxygen), and occasional collapse are common, especially following over-activity, excitement, or excessive heat or humidity. Obesity will aggravate these problems. Many dogs with elongated soft palates prefer to sleep on their backs. This is probably because this position allows the soft palate tissue to fall away from the larynx. The signs associated with stenotic nares and everted laryngeal saccules are similar. Stenotic nares can be easily diagnosed on physical examination. Definitive diagnosis of both elongated soft palate and everted laryngeal saccules can only be made with the dog under anesthesia. Generally, brachycephalic breeds have a thick tongue that makes visualization of the larynx in an awake animal very difficult. Attempts to restrain the patient and retract the tongue sufficiently to allow visualization of the larynx are generally unsuccessful. Under anesthesia, elongated soft palates extend past the tip of the epiglottis (the entrance to the airway). In severe cases the soft palate will extend directly into the laryngeal opening. The tip of the soft palate and the edges of the larynx are often inflamed (swollen and red). In chronic cases, the cartilages of the larynx become inflexible and begin to collapse, further narrowing the airway. Everted laryngeal saccules look like blue-gray soft tissue masses protruding into the airway just in front of the vocal folds. Your primary care veterinarian may also recommend chest x-rays to evaluate your pet’s lower airways and lungs. Soft palate abnormalities should be treated if they cause distress to your pet, become more severe with time, or cause life-threatening obstruction. If your pet shows gagging, coughing, exercise intolerance, or difficulty breathing, resection of the excess soft palate (staphylectomy) may be necessary. If the laryngeal saccules are everted, they may be removed at the same time as the soft palate resection, or they may be left in place and allowed to return to a more normal position. Correction of stenotic nares, if present, helps improve breathing and is done at the same time. After surgery, most dogs will have a good prognosis. They generally will breathe much easier and with significantly reduced respiratory distress and noise. However, most dogs will continue to have some level of residual respiratory noise. Their activity level can also markedly improve in many cases. Older animals may have a less favorable prognosis, especially if the process of laryngeal collapse has already started. If the laryngeal collapse is advanced, the prognosis is poor. I consent to the selected surgical procedure(s). *

I have read, understand, and consent

Procedure: *

Soft palate resection
Stenotic nares resection (if needed)
Everted laryngeal saccules transection (if present)

I hereby authorize Midwest Veterinary Surgery, LLC to perform an ovariohysterectomy (OHE) or Neuter (depending on the sex of the patient) on my pet. If the admitting veterinarian will be performing this procedure, rather than MVS, please indicate you do not authorize MVS to perform this procedure. *

I authorize
I do not authorize

Recovery: Your pet may need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incisions and prevent him/her from scratching or rubbing at the incisions. Most soft tissue surgeries take approximately 2-3 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2-3 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled activity. When not directly supervised, your pet must be confined to a crate. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. This surgical procedure can have an increased risk of anesthetic complication due to the condition of the patients it is performed on. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks

Surgical Risks Include: Pets must be monitored very closely immediately after surgery. Significant inflammation, swelling, or bleeding can obstruct the airway, making breathing difficult or impossible. Occasionally, a tube must be placed into the trachea through an incision in the neck (temporary tracheostomy), and maintained until the swelling in the throat subsides enough that the pet can breathe on its own. Pets are usually observed in the hospital for at least 24 hours. Post-operative coughing and gagging are common. Additional potential complications include nasal regurgitation as a result of palate shortening, aspiration pneumonia, infection, wound healing issues, and rarely, death. Risk of re-thickening of the palate and the need for additional trimming is reported, but is uncommon. In chronic cases in which the laryngeal cartilages have become inflexible, removal of the elongated soft palate and laryngeal saccules may not provide enough relief. The creation of a new permanent opening into the trachea in the neck area (called a permanent tracheostomy) may be the only solution, although there are complications associated with this procedure as well.

I have read and understand the risks

NOCITA (bupivacaine liposome injectable suspension) is a long-acting, local anesthetic that provides up to 72 hours of post-operative pain relief by releasing bupivacaine (anesthetic pain relief agent) over time from multivesicular liposomes. Dr. Swanson is happy to provide this additional form of pain medication during surgery for your patient if you would like to do so. Nocita is labeled for single-dose infiltration into the surgical site to provide local postoperative analgesia for cranial cruciate ligament surgery (TPLO, Extracapsular repair, etc) in dogs and as a nerve block in cats for declaw procedures. Like many drugs in the veterinary space that are used commonly, but not specifically labeled for veterinary medical usage, we offer Nocita usage for pain control for our surgical patients off label to be used where deemed appropriate and safe. * If performing castration (neuter) or ovariohysterectomy (spay) at the time of brachycephalic airway surgery, NOCITA can be administered along the incision: *

YES - I approve to have Nocita used at the time of surgery on my pet for pain control. I understand that in select instances it may be used off label when deemed safe by Dr. Swanson. Please check with your regular veterinary clinic if it is already included in your estimate. If not included in your original estimate, generally a single dose of Nocita runs $275.
NO - I do not approve Nocita pain control for my pet’s surgery.

Tail Amputation/Corkscrew Tail Amputation/Caudectomy

Your pet has been diagnosed with a condition affecting the tail that requires surgery. Indications for tail amputation include trauma, paralysis, neoplasia, and corkscrew tail/tail fold pyoderma. A corkscrew tail, also referred to as an “ingrown” tail is a congenital breed-related conformational abnormality that can be associated with secondary disease processes such as tail fold pyoderma and issues related to defecation. Due to breed-specific conformation, many of these patients also suffer from a recessed or “hooded” vulva that is also associated with skin fold pyoderma in addition to recurrent urinary tract infections (UTI). The level of tail amputation depends on the reason for the amputation. When performed to treat patients with paralysis of the tail or corkscrew tail (tail fold pyoderma) a cranial amputation, sometimes referred to as a high tail amputation or caudectomy, is performed. Amputation of the cranial part of the tail is performed at the level of the second or third caudal vertebra, which is cranial to the perineum. The surgical technique involves making a horizontal elliptical incision dorsal to the anus and incorporating the corkscrew tail/tail base and all diseased/infected areas affected by skin fold pyoderma. When performed for trauma or neoplasia, the location of the lesion dictates the level of the amputation. Before excision, we digitally approximate the planned surgical margins to confirm that closure can be performed with minimal tension at the surgical site. *

I have read and authorize

NOTE: If your surgeon has recommended performing an additional corrective procedure, such as an episioplasty, to address corkscrew conformation and associated vulvar skin fold pyoderma/recurrent UTI, please fill out the episioplasty/vulvoplasty surgical release as well. I consent to the selected surgical procedure(s).

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. This surgical procedure has an increased risk of anesthetic complication due to the breed of the patients it is performed on. We do not anticipate any in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage, incisional infection/dehiscence, bruising and swelling, transient incontinence due to surgery site swelling and inflammation, and tumor recurrence. *

I have read and understand the risks.

Cutaneous (Skin)/Subcutaneous Mass or Tumor Removal

Mass or tumor removals are not uncommon in dogs and cats. These can be tumors that grow in or around a major organ, subcutaneously under skin or be a part of the skin. These masses or tumors can be benign or malignant. A pre-surgical needle aspirate or biopsy is highly recommended, so the surgeon can know how aggressive to be at the time of removal. Malignant tumors need a wider margin of excision than benign tumors and have a higher chance for recurrence or spread to other parts of the body (metastasis). Unfortunately, sometimes it is impossible to get a definitive diagnosis without removing the entire tumor and submitting it for biopsy. Even with aggressive surgery, these tumors occasionally re-grow and need further surgery. Rarely, the tumor can be so invasive that complete excision is not possible without damaging the organ or structures (ie. blood vessels and nerves) that lie near the mass. I consent to the selected surgical procedure(s). *

I have read and authorize

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled activity. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. This surgical procedure can have an increased risk of anesthetic complication due to the condition of the patients it is performed on. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Hemorrhage, Incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation), tumor regrowth, inability to completely excise the mass (depending on location and invasiveness of the mass), and incomplete margins (potentially requiring additional surgery or other follow-up treatment). *

I have read and understand the risks.

Cystotomy

Your pet has been diagnosed with bladder stones (uroliths) that require surgical removal. There are several different types of bladder stones that can develop within the bladder or urinary tract of the dog/cat and complete surgical removal depends upon the size and location. Occasionally, these bladder stones can become lodged in different parts of the urinary tract (urethra and/or ureter) necessitating emergency surgery or treatment. Additionally, these bladder stones can cause chronic urinary tract infections if they are not removed. Certain types of breeds of dogs are predisposed to develop select types of bladder stones. I consent to the selected surgical procedure(s). *

I have read and authorize

Procedure: *

Cystotomy (opening up the bladder) and urolith (bladder stone) removal with stone analysis, culture and sensitivity testing, and histopathology (biopsy) of the bladder wall

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. This surgical procedure has an increased risk of anesthetic complication due to the condition of the patients it is performed on. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage, infection, uroabdomen (leakage of urine within the abdomen), bloody urine, temporary frequent urinations, and incisional complications (infection, dehiscence and/or seroma (fluid pocket) formation. I understand that some of these complications may require additional diagnostics and treatment at an additional cost). *

I have read and understand the risks.

Cystotomy/Scrotal Urethrostomy - Male Dogs

Your pet has been diagnosed with urinary bladder stones (calculi) that are causing an obstruction of the urethra preventing urination. In most cases the stones can be flushed from the urethra back into the bladder with retrograde urethral hydropulsion and removed via cystotomy (incision into the urinary bladder. However, sometimes a scrotal urethrostomy (permanent opening in the urethra) needs to be performed in addition to cystotomy due to frequent recurrent obstructions or inability to retropulse the stones into the bladder. If not already performed, these patients will need to be castrated (neutered) during the procedure due to the location of the surgical site in relation to the scrotum. Following scrotal urethrostomy, these patients are at an increased risk for recurrent urinary tract infections. The stones are submitted for analysis and culture at the time of surgery. Once the results are received, further recommendations regarding medical and dietary treatments will be made by your primary care veterinarian. I consent to the selected surgical procedure(s). *

I have read and authorize

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 3 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2-3 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 3 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled activity. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read and understand the risks.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. This surgical procedure can have an increased risk of anesthetic complication due to the condition of the patients it is performed on. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Hemorrhage, infection, uroabdomen (urine leakage into the abdomen), bloody urine, frequent urinations (temporary), stricture of the urethrostomy stoma, incisional complications (infection, dehiscence, and/or seroma), and increased risk for recurrent bladder infections. *

I have read and understand the risks.

Digit Amputation

Your pet needs to have a digit amputated from the forelimb or hindlimb due to irreparable damage, severe fracture injury, tumor, or chronic infection. The primary weight-bearing digits are the third and fourth digits. Typically the level of amputation in the digit is determined by the site affected and location within the limb. Electrosurgical equipment is utilized to diminish bleeding and swelling and pain and anesthesia is utilized to insure comfort upon awakening from the surgery. Bandages with splints are typically used postoperatively for 2-3 weeks with at least weekly bandage changes following digit amputations. While most patients do well following digit amputation, lameness typically results if more than two digits or the third or fourth digit is removed. Low-grade persistent lameness (pain or discomfort) after amputation of the third or fourth digit may occur. Digit amputation performed for tumor or mass removal does not guarantee complete removal of cancer cells. Complete staging, including thoracic radiographs, abdominal ultrasound, and cytological evaluation of draining lymph nodes, is strongly recommended prior to surgery, as metastasis (spread to other regions of the body) has often occurred. I consent to the selected surgical procedure(s). *

I have read and authorize

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage, seroma, infection and incisional dehiscence, and mass regrowth. I understand that some of these complications may require additional diagnostics and treatment at an additional cost. *

I have read and understand the risks.

Esophagostomy Tube Placement

Your pet requires an esophagostomy (feeding) tube placement to provide nutrition due to medical reasons that necessitate nutrition supplementation. This will require a minor surgical procedure under anesthesia. I consent to the selected surgical procedure(s). *

I have read and authorize

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. This surgical procedure can have an increased risk of anesthetic complication due to the condition of the patients it is performed on. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Complications associated with feeding tube placement and use of feeding tubes may also occur depending on what tube is utilized and include but are not limited to trauma with placement, intraoperative hemorrhage, accidental intubation of the respiratory tract, obstruction of the feeding tube with use, metabolic derangements, dislodgment and leakage of nutrition, surgical site infection, vomiting and/or diarrhea, and aspiration pneumonia. *

I have read and understand the risks.

External Abdominal Hernia Repair

Your pet has been diagnosed with an abdominal hernia (inguinal, scrotal, femoral, or umbilical) hernia that requires surgical repair. Hernias result from weakening of the abdominal musculature or normal opening where organs pass through. This can be congenital or traumatically induced. Umbilical hernias occur through the umbilical ring (most common). Inguinal hernias are protrusions of organs or tissue through the inguinal canal adjacent to the vaginal process. Scrotal hernias occur when defects in the inguinal ring allow abdominal contents to protrude into the vaginal process through the ring. Femoral hernias occur through a defect in the femoral canal (rare in small animals). The objectives of the surgery are to replace the contents of the hernial sac into the abdomen and reconstruct the holding layer to the ring or defect in abdominal musculature. Many different surgical techniques are available to the surgeon, but using a variety of suture techniques is performed most commonly to remove the hernia sac or repair the defect in the abdominal wall. On occasion, if your pet has very weak or insufficient muscles, a synthetic Marlex mesh is used to rebuild or reinforce the area. The overall success of a hernia repair (and often the prognosis for the patient) rarely depends on the repair itself, but more on management of the sequelae to organ herniation or trauma that impair normal body function. The severity of functional alteration depends on the cause, location, and content of the hernia. Important, often life-threatening, sequelae associated with abdominal hernias can be attributed to space-occupying effects (known as loss of domain) and abdominal organ incarceration, obstruction, or strangulation. The clinical condition of the animal at presentation, whether the hernia is open to the atmosphere or not, concurrent injuries to distant structures, and organ compromise from the trauma must also be factored when attempting to predict patient outcome. Prognosis for uncomplicated hernia repairs is good to excellent with a more guarded to poor prognosis for incarcerated or strangulated hernias. I consent to the selected surgical procedure(s). *

I have read and authorize

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the below-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: (Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks). This surgical procedure has an increased risk of anesthetic complication due to the breed of the patients it is performed on. We do not anticipate any in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage, hematoma formation, hernia recurrence, incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation, and peritonitis (inflammation within the abdomen). Additional complications for scrotal hernia repair include scrotal dermatitis and hematomas, which can be avoided by performing a scrotal ablation. Other organ specific complications can also occur depending on the abdominal organs affected by the hernia. *

I have read and understand the risks.

Exploratory Laparotomy Surgery

Your pet has been recommended to receive an exploratory surgery to identify abnormal contents within the abdomen (intestinal foreign body, mass or tumor, abscess, puncture wound, etc). The objective of surgery is to identify any abnormal areas or sections of organs and remove them. Oftentimes, more than one area is affected, however one specific organ or section of an organ can be affected only. The goal during surgery is to identify the abnormal contents within the abdomen and remove all or most of the abnormal contents or section of intestine that might be affected. This may require numerous incisions within the intestine or organ or removing a section of intestine or entire organ. Other organs within the abdomen can be affected and may need to be removed including the gastrointestinal tract, urinary tract, liver and biliary tree, spleen, or pancreas. Many different surgical techniques are available to the surgeon but using a variety of suture or electrosurgical techniques (Ligasure), the abnormal section will be removed or debulked as necessary. Other intestinal organ biopsies may be warranted. Although every effort is made to prevent or minimize complications, any surgery near these important structures are not without complications. I consent to the selected surgical procedure(s). *

I have read and authorize

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. This surgical procedure may have an increased risk of anesthetic complication due to the condition of the patients it is performed on. We do not anticipate any in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: General abdominal surgery risks include intraoperative hemorrhage, incisional complications (infection, dehiscence, and/or seroma formation), bruising and swelling. Additional surgical complications of exploratory laparotomy are related to the organs affected and the surgical procedures performed. These can include, but are not limited to, septic peritonitis (ie. leakage of intestinal or biliary contents into the abdominal cavity), gastrointestinal ileus (slowing down of the GI tract), clotting disorders, cardiac arrhythmias, respiratory difficulty, and/or death. *

I have read and understand the risks.

Extracapsular Cranial Cruciate Stabilization

Your pet has been diagnosed with a suspected ruptured cranial cruciate ligament (CCL - equivalent to the ACL in a human) that requires surgical stabilization. The lateral suture technique involves wrapping a heavy gauge nylon suture around the stifle to stabilize it long enough for organized scar tissue to form around the joint. The suture has a limited functional lifespan, and will eventually stretch out or break, the hope is that this happens after enough scar tissue has formed to ultimately provide long-term stability for the joint. For this reason, lateral sutures are generally only recommended for patients that are less than 20 pounds or in patients that are not very active, as the functional lifespan of the suture tends to be shorter in larger dogs or those that are very active. In many cases of CCL rupture, the medial and/or lateral meniscus (shock absorber cartilages in the knee) are torn as well, and the torn portion needs to be removed. When the meniscus is torn, osteoarthritis (OA) tends to develop more rapidly compared to a knee with a normal meniscus. However, all patients that have CCL rupture are prone to develop stifle osteoarthritis. If indicated, multimodal management of OA can include the use of fish oil (Omega-3 fatty acids), Adequan, glucosamine chondroitin, intermittent pain medication use, and therapeutic diets. Approximately 40-60% of dogs that rupture one CCL will go on to rupture the other CCL typically within 1-2 years. The goal of any orthopedic surgery is rapid bone healing with return to normal/improved function. Most patients undergoing extracapsular stabilization surgery will heal without complication in approximately 8-12 weeks with a good to excellent prognosis. However, peak recovery is generally not achieved until 4-6 months postoperatively. Patients need to be crate rested for 8 at least 8-12 weeks to provide the best chance for recovery and minimize the chance for complications. I consent to the selected surgical procedure(s). *

I have read and authorize

For additional information regarding Cranial Cruciate Disease and its treatment please refer to the following handout: TPLO/CCL Handout.

My pet is having surgery today on the:

Right Hindlimb
Left Hindlimb

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most orthopedic surgeries take approximately 8-12 weeks for healing to occur. This means that the implants used for repair/stabilization are responsible for bearing most, if not all, of the weight that is placed on the limb until complete healing has occurred. To protect the repair and maximize potential healing, your pet will need to be crate rested during this 8-12 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage, implant failure (suture breaking/stretching out prematurely) leading to recurrent instability, implant infection (possibly necessitating removal once sufficient healing has occurred for an additional cost), postoperative meniscal injury, incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation - swelling around the ankle can occur due to gravity pulling the fluid towards the foot), and potential lameness due to osteoarthritis development. *

I have read and understand the risks.

Extracapsular Cranial Cruciate Stabilization & Patellar Luxation

Your pet has been diagnosed with a suspected ruptured cranial cruciate ligament (CCL - equivalent to the ACL in a human) that requires surgical stabilization. The lateral suture technique involves wrapping a heavy gauge nylon suture around the stifle to stabilize it long enough for organized scar tissue to form around the joint. The suture has a limited functional lifespan, and will eventually stretch out or break, the hope is that this happens after enough scar tissue has formed to ultimately provide long-term stability for the joint. For this reason, lateral sutures are generally only recommended for patients that are less than 20 pounds or in patients that are not very active, as the functional lifespan of the suture tends to be shorter in larger dogs or those that are very active. The surgeon will also evaluate your pet’s stifle joint during the procedure to determine the best method of patellar stabilization given your pet’s grade of luxation and underlying joint confirmation. The surgeon may utilize one or more methods of repair depending upon what is found in surgery. Methods of patellar stabilization include: tibial tuberosity transposition, trochlear wedge or block recession, medial or lateral joint capsule release, and medial or lateral joint capsule imbrication (tightening of soft tissues). These techniques are oftentimes performed in combination. In many cases of CCL rupture, the medial and/or lateral meniscus (shock absorber cartilages in the knee) are torn as well, and the torn portion needs to be removed. When the meniscus is torn, osteoarthritis (OA) tends to develop more rapidly compared to a knee with a normal meniscus. However, all patients that have CCL rupture are prone to develop stifle osteoarthritis. If indicated, multimodal management of OA can include the use of fish oil (Omega-3 fatty acids), Adequan, glucosamine chondroitin, intermittent pain medication use, and therapeutic diets. Approximately 40-60% of dogs that rupture one CCL will go on to rupture the other CCL typically within 1-2 years. The goal of any orthopedic surgery is rapid bone healing with return to normal/improved function. Most patients undergoing extracapsular stabilization with patellar luxation correction surgery will heal without complication in approximately 8-12 weeks with a good to excellent prognosis. However, peak recovery is generally not achieved until 4-6 months postoperatively. Patients need to be crate rested until the bone has healed to provide the best chance for recovery and minimize the chance for complications. I consent to the selected surgical procedure(s). *

I have read and authorize

For additional information regarding Cranial Cruciate Disease and its treatment please refer to the following handout: TPLO/CCL Handout.

My pet is having surgery today on the:

Right Hindlimb
Left Hindlimb

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most orthopedic surgeries take approximately 8-12 weeks for healing to occur. This means that the implants used for repair/stabilization are responsible for bearing most, if not all, of the weight that is placed on the affected limb until complete healing has occurred. To protect the repair and maximize potential healing, your pet will need to be crate rested during this 8-12 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage, implant failure (suture breaking/stretching out prematurely, pins breaking or backing out, etc.) leading to recurrent instability requiring additional surgery (for an additional cost), implant infection (possibly necessitating removal once sufficient healing has occurred for an additional cost), implant irritation of the soft tissues, incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation - swelling around the ankle can occur due to gravity pulling the fluid towards the foot), patellar reluxation, postoperative meniscal tear, lameness long-term due to osteoarthritis (OA). *

I have read and understand the risks.

Femoral Head and Neck Ostectomy (FHNO)

Your pet has been diagnosed with a hip disease/injury that cannot be repaired. You have elected to have a “salvage” procedure called a femoral head and neck ostectomy (FHNO or FHNE or FHO) performed where we excise the ball portion of the “ball and socket” hip joint creating a “false joint”. Following and FHNO, the gluteal muscles become responsible for transferring the weight bearing forces of the limb to the pelvis. This procedure is effective at relieving pain associated with “bone-on-bone” contact between the femoral head and the pelvis, it does not recreate a normal hip coxofemoral joint. This means some patients, especially larger patients, may develop a mechanical lameness and gait change following this procedure. Aggressive postoperative rehabilitation therapy is strongly recommended and necessary to achieve the best possible outcome following this surgery. Peak recovery following an FHNO can take up to 4-6 months. I consent to the selected surgical procedure(s). *

I have read and authorize

My pet is having surgery today on the:

Left Leg
Right Leg

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. This procedure takes approximately 2 weeks for healing to occur postoperatively. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage, sciatic nerve injury, mechanical lameness, decreased range of motion of the hip, patellar luxation, surgical site infection, and incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation - swelling around the ankle can occur due to gravity pulling the fluid towards the foot). *

I have read and understand the risks.

Fracture Repair

Your pet has been diagnosed with a fractured bone that needs surgical repair. The orthopedic surgeon will evaluate your pet’s radiographs and determine the best method of repair given your pet’s age, type of fracture or fractures, and the home environment for post-surgical recovery and rehabilitation. The surgeon may utilize a combination of pins, wires, screws, and/or bone plates for repair. The goal of any orthopedic surgery is rapid bone healing with return to normal function. Many times the method of repair can only be properly determined during surgery as fissures (small cracks in the bone) and small fragments may not show up on a radiograph, precluding certain types of fixation that would split the bone and worsen the fracture. In the case of severely comminuted fractures or those with very small fragments, especially those near joints, primary fracture repair may not be possible. Most patients undergoing fracture repair will heal without complication in approximately 8-12 weeks. Patients need to be crate rested during that entire recovery time to provide the best chance for recovery and minimize the chance for complications. I consent to the selected surgical procedure(s). *

I have read and authorize

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most orthopedic surgeries take approximately 8-12 weeks for healing to occur. This means that the implants used for repair/stabilization are responsible for bearing most, if not all, of the weight that is placed on the affected limb until complete healing has occurred. To protect the repair and maximize potential healing, your pet will need to be crate rested during this 8-12 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage, implant failure (typically requiring additional surgery for an additional cost), implant infection (possibly necessitating removal once sufficient healing has occurred for an additional cost), potential for delayed bony union or nonunion, incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation), refracture of the bone, and lameness longterm due to long-term bone sensitivity and/or osteoarthritis (OA) formation. Generally implant failure is seen if there is too much activity during the initial recovery period. Additional Surgical Risks for Young Animals: While they tend to heal faster than adults, the immature bones of young animals are softer than adult bones, so the chance of implant migration/loosening may be higher in these patients. Subtle physeal (growth plate) trauma can also occur in young animals leading to growth disturbances that are not appreciated until the animal continues to grow. *

I have read and understand the risks.

Cholecystectomy/Gallbladder Removal

Your pet has been diagnosed with a disease process of the gallbladder. The gallbladder is the part of the liver and biliary system that stores bile after it is made in the liver. After eating a meal, the gallbladder contracts to release the stored bile into the intestinal tract via the common bile duct to aid in digestion of food. The biliary system can become obstructed when the gallbladder fills with sludge or stones that block the normal flow of bile with the most common disease process being a gallbladder mucocele. In most cases, surgically removing the gallbladder (cholecystectomy) is all that is needed to resolve the problem. Occasionally, the problem can be more severe and involve a ruptured common bile duct with leakage of bile, tumors obstructing the duct, or infection that leaks into the liver tissue causing jaundice (yellow skin staining). In cases of common bile duct obstruction, we may need to reroute the bile flow from the gallbladder directly into the small intestine bypassing the obstruction. In many cases, patients with biliary obstruction also have underlying liver dysfunction, which can increase their risk of undergoing anesthesia, but without surgery this condition can become fatal. The risk of perioperative death for cholecystectomy surgery is approximately 20-30%, though patients that survive the immediate perioperative period typically have a good prognosis. I consent to the selected surgical procedure(s). *

I have read and authorize

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. This surgical procedure can have an increased risk of anesthetic complication due to the condition of the patients it is performed on. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Hemorrhage, postoperative bile leakage leading to peritonitis (inflammation with the abdominal cavity), infection, pancreatitis, incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation, and uncommonly, death. *

I have read and understand the risks.

Implant Removal (Bone Plate/Screws, IM Pin, or Nylon Suture)

While most patients keep their orthopedic implants for the remainder of their lives, it has been determined that sufficient bone has occurred, and it is in the best interest of your pet to remove the implants from his/her previous orthopedic surgery. In most cases, this is due to either bone sensitivity or implant infection. In the case of implant infection, the bacteria form a biofilm around the implants, which is a sticky substance that protects the bacteria from the immune system and antibiotics. The only way to fully eradicate the infection is to remove the implants. Once the implants are removed they are generally submitted for culture testing to determine the correct antibiotics necessary to clear the infection. Your pet will receive a broad spectrum antibiotic while we wait for the culture results to be received, which typically takes approximately 7-10 days. Once the results are, recommendations will be made as to whether the current antibiotic will either be continued or changed based on the results. I consent to the selected surgical procedure(s). *

I have read and authorize

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Persistent infection, incisional complications (infection, dehiscence, or seroma (fluid accumulation) formation), and screw hole fracture (rare). *

I have read and understand the risks.

Leg Amputation

Your pet has been diagnosed with a condition that necessitates having his/her leg amputated due to irreparable damage, severe fracture injury, tumor, or muscle, tendon or blood supply/nerve damage. Amputation of a forelimb, involves removal of the entire limb including the scapula (shoulder blade) to provide a more cosmetic appearance and decrease the risk of pressure sore development over the scapular spine due to muscle atrophy. Hindlimb amputation involves removal of the entire hindlimb by disarticulation at the level of the hip joint. There are a number of variables that may limit how well a pet will do with an amputation including obesity, concurrent orthopedic or neurologic abnormalities, large patient size, and forelimb vs hindlimb amputation. The forelimbs bear more weight than the hindlimbs, and therefore forelimb amputation tends to impact mobility more than hindlimb amputation. However, most patients adapt and do very well following amputation. I consent to the selected surgical procedure(s). *

I have read and authorize

My pet is having surgery today on the:

Limb *

Front Leg
Rear Leg

Side *

Left
Right

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. This surgical procedure can have an increased risk of anesthetic complication due to the condition of the patients it is performed on. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage and incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation), and initial difficulty ambulating. *

I have read and understand the risks.

Liver Surgery

Your pet has been diagnosed with a liver condition that requires biopsy or liver mass (tumor or growth) that needs to be excised and biopsied. Depending on the size and location of the mass, either a partial or complete liver lobectomy will be performed. Pets can live safely without complications as long as less than 60% of the liver is removed. The most common primary liver tumors are hepatocellular carcinoma (HCC) in dogs and hepatocellular adenoma in cats. There are three types of HCC including massive (single large mass), nodular, and diffuse with massive being the most common. The metastatic rate (spread to other places) is much lower for massive HCC (0-37%) compared to nodular and diffuse (93-100%). Since chemotherapy is generally not effective for HCC, surgery is the best treatment option for massive HCC. The reported prognosis is generally good for dogs that survive the perioperative period with massive HCC that is completely excised with a median survival time of > 1,460 days. In some cases, we may find that the liver mass is non-resectable. This means that it cannot be removed without being fatal. If this is found to be the case you will be contacted intraoperatively and the findings and recommendations will be discussed with you over the phone. The biggest complication of liver surgery is hemorrhage both during and after surgery. If hemorrhage is severe, your pet may require a blood transfusion. I consent to the selected surgical procedure(s). *

I have read and authorize

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. This surgical procedure can have an increased risk of anesthetic complication due to the condition of the patients it is performed on. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intra- and postoperative hemorrhage, coagulopathy (inability to form blood clots), thromboembolic disease (formation of blood clots that break off and obstruct blood flow in vessels), pancreatitis, incisional complications (infection, dehiscence, and seroma (fluid accumulation) formation), tumor regrowth, and rarely, death. *

I have read and understand the risks.

Patella Luxation (MPL/LPL)

Your pet has been diagnosed with a luxating patella that needs surgical repair. The surgeon will evaluate your pet’s stifle joint during the procedure to determine the best method of patellar stabilization given your pet’s grade of luxation and underlying joint confirmation. The surgeon may utilize one or more methods of repair depending upon what is found in surgery. Methods of patellar stabilization include: tibial tuberosity transposition, trochlear wedge or block recession, medial or lateral joint capsule release, and medial or lateral joint capsule imbrication (tightening of soft tissues). These techniques are oftentimes performed in combination. The prognosis for most dogs following patella luxation correction surgery is very good, though peak recovery may not be achieved until 4-6 months after surgery. Patients with patellar luxation may develop stifle osteoarthritis (OA). If indicated, multimodal management of OA can include the use of fish oil (Omega-3 fatty acids), Adequan, glucosamine chondroitin, intermittent pain medication use, and therapeutic diets. The goal of any orthopedic surgery is rapid bone healing with return to normal/improved function. Most patients undergoing patellar luxation repair will heal without complication in approximately 8-12 weeks. Patients need to be crate rested during that entire recovery time to provide the best chance for recovery and minimize the chance for complications. I consent to the selected surgical procedure(s). *

I have read and authorize

My pet is having surgery today on the: *

Left Hindlimb
Right Hindlimb
Both Hindlimbs

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most orthopedic surgeries take approximately 8-12 weeks for healing to occur. This means that the implants used for repair/stabilization are responsible for bearing most, if not all, of the weight that is placed on the limb until complete healing has occurred. To protect the repair and maximize potential healing, your pet will need to be crate rested during this 8-12 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage, implant failure/migration or implant irritation of the soft tissues (likely requiring additional surgery for an additional cost), implant infection (possibly necessitating removal once sufficient healing has occurred for an additional cost), transposition failure, recurrent luxation, incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation - swelling around the ankle can occur due to gravity pulling the fluid towards the foot), and lameness long-term due to development of osteoarthritis. *

I have read and understand the risks.

Perianal Mass Removal

Perianal masses are most commonly benign adenomas. However, more aggressive adenocarcinomas can also arise from the sebaceous glands of the perianal region. Perianal adenomas frequently develop secondary to androgen stimulation, and occur predominantly in intact males and spayed females, as low estrogen levels do not suppress tumor growth. They can also be associated with hyperadrenocorticism or adrenal tumors producing testosterone. Diagnosis is typically obtained via fine needle aspirate and cytology, though it can be difficult to differentiate benign from malignant masses. Treatment typically involves castration (to minimize the chance of recurrence) +/- local tumor resection. In the case of large tumors, complete excision may not be possible without damaging the rectum or the nerves that control defecation. The prognosis following castration and surgical resection is excellent with a <10% recurrence rate. I consent to the selected procedure. *

I have read and authorize

Procedure: *

Neuter (Castration) - If intact male
Perianal Gland Tumor Excision

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage, incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation), bruising and swelling, transient incontinence due to surgery site swelling and inflammation, and tumor recurrence. *

I have read and understand the risks.

Perineal Hernia Repair

Your pet has been diagnosed with a perineal hernia that requires surgical repair. Perineal hernias result from testosterone-mediated weakening of the pelvic diaphragm muscles. They occur most commonly in intact male dogs or dogs neutered later in life. The objectives of the surgery are to replace the contents of the hernia sac (commonly includes the colon, fluid, fat, and sometimes the urinary bladder and/or small intestine) back into the abdomen and reconstruct the pelvic diaphragm. In cases where the urinary bladder has become entrapped in the hernia sac, acute urinary obstruction can occur, which can be life threatening. The most common surgical technique used for treatment is the internal obturator muscle transposition. However, some cases may require additional techniques, such as utilizing mesh to support the pelvic diaphragm or abdominal procedures such as vas deferens pexy, cystopexy (urinary bladder tacking), or colopexy (large intestine tacking), especially when abdominal organs are herniated. Since mesh is an implant, if infection occurs, it may need to be removed. In dogs that are still intact, concurrent castration (neutering) is necessary to significantly reduce the risk of hernia recurrence. Overall, most dogs recover well following surgery, though many may strain to defecate postoperatively and may need to be placed on stool softeners and/or higher fiber diets. I consent to the selected surgical procedure(s). *

I have read and authorize

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Hemorrhage, surgical site infection, fecal incontinence, nerve damage to the nerves of the rectum, hernia recurrence, rectal prolapse, incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation), and rarely, death. *

I have read and understand the risks.

Perineal Urethrostomy (PU) - Cat

Your pet has been diagnosed with a blocked urethra due to feline lower urinary tract disease or urinary stones, which requires surgery to relieve the obstruction. Feline lower urinary tract disease (FLUTD) describes a variety of conditions that affect the bladder and urethra in cats. Clinical signs associated with FLUTD most often include difficulty and pain when urinating, increased trips to the litter box, excessive licking, blood in the urine, and possibly urinating outside of the litter box. FLUTD can occur at any age, but is typically seen in middle-aged, overweight cats that use an indoor litter box, or eat a dry diet. Multiple environmental factors can also increase the risk for development of FLUTD including stress, multi-cat households, and abrupt changes to the daily routine. In severe cases, cats can develop potentially life-threatening obstruction of their urethra, which is the tube that connects the urinary bladder to the out of the body through the penis. These cats pass very little to no urine and become increasingly distressed. Obstruction occurs most often in male cats due to their urethra being longer and more narrow than the urethra of female cats. Obstruction often results due to plugs of inflammatory material (mucus, crystals, and cells) or urinary stones. Cats with urethral obstruction require immediate emergency veterinary treatment, as the inability to urinate can be fatal within a few days. With appropriate care including urethra catheterization, IV fluids, and pain medications, these bouts of obstruction can resolve in 5-7 days. However, cats will have recurrence of obstruction within 6-12 months. If obstruction recurs or cannot be relieved, surgery to widen the urethral opening, or perineal urethrostomy (PU), is typically recommended. The PU should prevent the obstruction again, but will not prevent the other signs associated with feline lower urinary tract disease. The patient is expected to be able to pass the debris out though the larger PU opening. The success of this surgery depends upon a healthy urethra, which can not be fully determined until it is evaluated during surgery. In some cases, scar tissue or lacerations can affect the ability of the surgeon to perform the PU surgery. In rare cases, there are strictures or lacerations within the pelvic urethra, requiring an abdominal procedure to expose the bladder and urethra and create a new opening on the abdominal wall for urine to drain. I consent to the selected surgical procedure(s). *

I have read and authorize

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 3 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision, as trauma to the site can lead to stricture of the uresthrostomy stoma leading to urinary obstruction. Most perineal urethrostomy surgery sites take approximately 3 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 3 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled activity. When not directly supervised, your pet must be confined to a crate. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. This surgical procedure can have an increased risk of anesthetic complication due to the condition of the patients it is performed on. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Surgical site infection, hemorrhage, stricture (may require additional surgery for an additional cost), urinary tract infections due to a shorter urethra, urine scald, perineal hernia, incisional complications (infection, dehiscence and/or seroma (fluid accumulation) formation), and rarely death. *

I have read and understand the risks.

Prophylactic Gastropexy

You have elected to perform a prophylactic (preventative) technique on your pet due to their increased risk of developing a severe, life-threatening condition called gastric dilatation and volvulus (GDV) or bloat. The underlying cause of GDV is not completely understood. However, specific risk factors for GDV have been identified in dogs and include purebred large or giant breed, deep chested dogs, history of GDV in a first-degree relative, feeding fewer meals per day, eating rapidly, aggressive or fearful temperament, decreased food particle size, and exercise or stress after a meal. This disease presents acutely with the stomach flipping over on itself and trapping a large amount of gas and fluid within the lumen of the stomach. This puts significant pressure on the abdominal organs, blood vessels, and diaphragm leading to decreased blood flow throughout the body, which can lead to possible death if not surgically corrected in a timely fashion. Therefore, you have elected to surgically tack the stomach to the abdominal body wall in order to prevent the life-threatening volvulus event (twisting of the stomach). However, this technique will not definitively prevent future gastric distension, therefore, if pain is noted within the abdominal region, please seek immediate veterinary assistance. I consent to the selected surgical procedure(s). *

I have read and authorize

I hereby authorize Midwest Veterinary Surgery, LLC to perform an ovariohysterectomy (OHE) or Neuter (depending on the sex of the patient) on my pet. If the admitting veterinarian will be performing this procedure, rather than MVS, please indicate you do not authorize MVS to perform this procedure. *

I authorize
I do not authorize

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage, gastric outflow obstruction, surgical site infection, and incisional complications (infection, dehiscence, and seroma (fluid accumulation) formation). *

I have read and understand the risks.

Salivary Mucocele/Sialocele

Your pet has been diagnosed with a salivary mucocele (sialocele) that requires surgical removal. Sialoceles form as a result of trauma (nonsurgical and surgical), sialoliths (stones), foreign bodies, and neoplasia causing blockage or tearing of the duct leading from the salivary gland to the mouth. However, in most cases an underlying cause is not identified. There are six different salivary glands on each side of the head and in most cases, the mandibular/sublingual salivary gland complex is the one that is causing the problem. In some patients, imaging (CT scan) and other diagnostic tests may need to be performed before surgery (or after surgery if the mucocele recurs) to determine which gland is involved. Surgery involves removing the affected gland and associated duct, as well as draining the saliva filled mucocele. The location of the mucocele swelling (under the neck, under the tongue, back of the throat, or under the eye) is determined based on the gland involved, which also determines the surgical technique utilized. Dry mouth is rarely an issue following removal of a salivary gland, as there are numerous other salivary glands. I consent to the selected surgical procedure(s). *

I have read and authorize

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read and understand the risks.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. This surgical procedure can have an increased risk of anesthetic complication due to the condition of the patients it is performed on. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage, surgical site infection, recurrence of the sialocele (<5%), sublingual (under the tongue) swelling and incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation). *

I have read and understand the risks.

Splenectomy

The spleen is a vascular organ responsible for filtering the blood to remove infectious agents and abnormal blood cells, assisting in the production of new red blood cells, and acting as a reservoir to store a portion of the red blood cells and platelets until they are needed. Your pet has been diagnosed with a condition of the spleen that requires its surgical removal with splenic masses being the most commonly indicated condition. Masses associated with the spleen are common in older dogs with approximately 50-75% of them being malignant (cancer). The most common type of splenic cancer is hemangiosarcoma (HSA), which is a cancer of the cells lining the blood vessels. Other common types of masses in the spleen include benign hematomas and hemangiomas with other types of cancer occurring less frequently. Approximately 25% of dogs with splenic HSA also have concurrent right atrial (heart) HSA. Splenic tumors, especially HSA, tend to be cavitated (blood filled) and can rupture leading to a hemoabdomen (bleeding into the abdominal cavity), which is a life-threatening surgical emergency. HSA is highly metastatic (readily spreads to other places in the body) with the most common site for spread being the lungs. Metastatic nodules in other organs or tissues may be seen at the time of surgery, and if noted we will call intraoperatively to discuss the findings during the procedure. It is not possible to determine if a splenic mass is benign or malignant without histopathological evaluation (biopsy), so surgical removal of splenic masses is the recommended treatment. Preoperatively staging should be performed including complete blood work, thoracic radiographs and abdominal ultrasound prior to surgery. An echocardiogram should also be considered to evaluate the heart for evidence of metastasis. If HSA is diagnosed, the prognosis is poor. The average survival time with surgery alone is approximately 3-4 months, and with postoperative chemotherapy is approximately 6-8 months. If the mass is benign, the surgery is typically curative. Additional recommendations regarding treatment and any further diagnostics will be made once the histopathology results are received. I consent to the selected surgical procedure(s). *

I have read and authorize

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. This surgical procedure can have an increased risk of anesthetic complication due to the condition of the patients it is performed on. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. (copy) *

I have read and understand the risks.

Surgical Risks Include: Hemorrhage, vascular compromise of the pancreas or portal vein (blood vessel that drains the abdominal organs to the liver), cardiac arrhythmias, life-threatening systemic inflammatory derangements including disseminated intravascular coagulation (DIC - clotting in the blood vessels throughout the body), pulmonary thromboembolism (clots in the vessels of the lungs), acute respiratory distress syndrome (ARDS - allows fluid accumulation in the lungs), and/or systemic inflammatory response syndrome (SIRS - exaggerated defense response by the body to a stressor), gastric dilatation volvulus (GDV or bloat), blood infection, potential for decreased oxygen transport, and incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation, and possibly death. *

I have read and understand the risks.

Superficial Digital Flexor Tendon (SDFT) Luxation Repair

Your pet has been diagnosed with a luxating superficial digital flexor tendon, whereby the tendon slides medially or laterally off the point of the calcaneus (heel). This injury occurs spontaneously during vigorous activity. This is a severe injury that if left unrepaired will result in a severe lameness. The longer the condition is untreated, the higher the likelihood of scar tissue formation and possible failure of the repair. Medical management with casts, splints or bandages alone is usually unsatisfactory. Surgery involves mobilizing and suturing the surrounding tissues of the SDFT to secure it into its appropriate position over the point of the calcaneus. Following surgery, the tarsal (ankle) joint is immobilized with a bandage and splint/cast for at least 4-6 weeks. The bandage will need to be changed weekly until it is removed. The goal of any orthopedic surgery is rapid healing with return to normal/improved function. Most patients undergoing SDFT luxation surgery will heal without complication in approximately 4-8 weeks with a good prognosis. Patients need to be crate rested during the entire recovery period to provide the best chance for recovery and minimize the chance for complications. Once the bandage is removed gradual return to normal activity is recommended over another 4 weeks. This disease process is overrepresented in collie and Sheltie breeds. I consent to the selected surgical procedure(s). *

I have read and authorize

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. This condition takes approximately 4-8 weeks for healing to occur following surgery. To protect the repair and maximize potential bone healing, your pet will need to be crate rested during this 4-8 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled activity. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read and authorize

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage, tendon reluxation, surgical site infection, continued lameness long-term, and incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation. *

I have read and understand the risks.

Synovial Fluid Aspirate (Joint Tap)

Your pet has a suspected pathology in one or more of its joints that requires sampling of the joint fluid to obtain additional diagnostic information. The surgeon will shave and aseptically prepare the region around the joint before performing the joint tap procedure. The surgeon will use a needle to sample the (synovial) fluid found within the joint(s). Depending upon the suspected underlying pathology, this fluid will be used to prepare multiple microscope slides for cytological evaluation as well as retaining samples for cellular counts and bacterial culture and sensitivity testing. These samples can also be used to identify fungal organisms and look for indications of underlying immune- mediated disease(s). Multiple samples will be retained as this is important to help identify the cause of your pet’s underlying issue(s) and further direct your pet’s treatment recommendations. Unfortunately, there are some instances where sampling of the affected region does not yield an answer. This can be due to a number of underlying biological and diagnostic factors that may be out of our control, but every effort is made to obtain diagnostic samples from your pet. Additionally, sometimes the surgeon may simultaneously therapeutically deliver steroids within the joint. Once the diagnostic results are received, further recommendations regarding treatment and/or additional diagnostics will be made. I consent to the selected surgical procedure(s). *

I have read and authorize

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment(s) and/or diagnostic(s) as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me, and no guarantee has been made as to results or cure. I understand that there may be risks involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks

Risks Include: Joint infection, hemorrhage, swelling, and bruising. *

I have read and understand the risks

TPLO - Cranial Cruciate Ligament Rupture Stabilization

Your pet has been diagnosed with a suspected ruptured cranial cruciate ligament (CCL - equivalent to the ACL in a human) that will benefit from a tibial plateau leveling osteotomy (TPLO) procedure. Other techniques are available for treating this condition, however based on the size of your dog and/or their activity level your referring veterinarian and I believe the TPLO procedure is most appropriate for your pet. The TPLO procedure involves making a semicircular (biradial) cut in the top portion of the tibia (shin bone), rotating it into a new position, and securing it in place with a bone plate and screws. Thereby, changing the biomechanics of the knee, so it is stabilized without needing the CCL to be intact, thus creating a stable leg on which your pet can walk. In many cases, the medial and/or lateral meniscus (shock absorber cartilages in the knee) are torn as well, and the torn portion needs to be removed. When the meniscus is torn, osteoarthritis (OA) tends to develop more rapidly compared to a knee with a normal meniscus. However, all patients that have CCL rupture are prone to develop stifle osteoarthritis. If indicated, multimodal management of OA can include the use of fish oil (Omega-3 fatty acids), Adequan, glucosamine chondroitin, intermittent pain medication use, and therapeutic diets. Approximately 40-60% of dogs that rupture one CCL will go on to rupture the other CCL typically within 1-2 years. The goal of any orthopedic surgery is rapid bone healing with return to normal/improved function. Most patients undergoing TPLO surgery will heal without complication in approximately 8-12 weeks with a good to excellent prognosis. However, peak recovery is generally not achieved until 4-6 months postoperatively. Patients need to be crate rested until the bone has healed to provide the best chance for recovery and minimize the chance for complications. I consent to the selected surgical procedure(s). *

I have read and authorize

For additional information regarding Cranial Cruciate Disease and its treatment please refer to the following handout: TPLO/CCL Handout.

My pet is having surgery today on the: *

Left Hindlimb
Right Hindlimb

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most orthopedic surgeries take approximately 8-12 weeks for bone healing to occur. This means that the implants used for repair are responsible for bearing most, if not all, of the weight that is placed on the affected limb until complete healing has occurred. To protect the repair and maximize potential bone healing, your pet will need to be crate rested during this 8-12 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled activity. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage, implant failure (bone plate breaking, screws breaking/backing out, etc.), tibial tuberosity fracture, implant infection (possibly necessitating removal once sufficient healing has occurred for an additional cost), patellar tendinosis (inflammation of the patellar ligament), postoperative meniscal injury, incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation - swelling around the ankle can occur due to gravity pulling the fluid towards the foot), and potential lameness due to osteoarthritis development or long-term bone sensitivity. *

I have read and understand the risks.

TPLO & Patellar Luxation

Your pet has been diagnosed with a suspected ruptured cranial cruciate ligament (CCL - equivalent to the ACL in a human) that will benefit from a tibial plateau leveling osteotomy (TPLO) procedure and a luxating patella that needs surgical repair. Other techniques are available for treating CCL rupture, however based on the size of your dog and/or their activity level your referring veterinarian and I believe the TPLO procedure is most appropriate for your pet. The TPLO procedure involves making a semicircular (biradial) cut in the top portion of the tibia (shin bone), rotating it into a new position, and securing it in place with a bone plate and screws. Thereby, changing the biomechanics of the knee, so it is stabilized without needing the CCL to be intact, thus creating a stable leg on which your pet can walk. The surgeon will also evaluate your pet’s stifle joint during the procedure to determine the best method of patellar stabilization given your pet’s grade of luxation and underlying joint confirmation. The surgeon may utilize one or more methods of repair depending upon what is found in surgery. Methods of patellar stabilization include: tibial tuberosity transposition, trochlear wedge or block recession, medial or lateral joint capsule release, and medial or lateral joint capsule imbrication (tightening of soft tissues). These techniques are oftentimes performed in combination. In many cases of CCL rupture, the medial and/or lateral meniscus (shock absorber cartilages in the knee) are torn as well, and the torn portion needs to be removed. When the meniscus is torn, osteoarthritis (OA) tends to develop more rapidly compared to a knee with a normal meniscus. However, all patients that have CCL rupture are prone to develop stifle osteoarthritis. If indicated, multimodal management of OA can include the use of fish oil (Omega-3 fatty acids), Adequan, glucosamine chondroitin, intermittent pain medication use, and therapeutic diets. Approximately 40-60% of dogs that rupture one CCL will go on to rupture the other CCL typically within 1-2 years. The goal of any orthopedic surgery is rapid bone healing with return to normal/improved function. Most patients undergoing TPLO with patellar luxation correction surgery will heal without complication in approximately 8-12 weeks with a good to excellent prognosis. However, peak recovery is generally not achieved until 4-6 months postoperatively. Patients need to be crate rested until the bone has healed to provide the best chance for recovery and minimize the chance for complications. I consent to the selected surgical procedure(s). *

I have read and authorize

For additional information regarding Cranial Cruciate Disease and its treatment please refer to the following handout: TPLO/CCL Handout.

My pet is having surgery today on the: *

Left Hindlimb
Right Hindlimb

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most orthopedic surgeries take approximately 8-12 weeks for bone healing to occur. This means that the implants used for repair are responsible for bearing most, if not all, of the weight that is placed on the affected limb until complete healing has occurred. To protect the repair and maximize potential bone healing, your pet will need to be crate rested during this 8-12 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled activity. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage, implant failure (bone plate breaking, screws backing out/breaking, ect.), tibial tuberosity fracture, implant infection (possibly necessitating removal once sufficient healing has occurred for an additional cost), patellar tendinosis (inflammation of the patellar ligament), postoperative meniscal injury, patellar reluxation, incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation - swelling around the ankle can occur due to gravity pulling the fluid towards the foot), and potential lameness due to osteoarthritis development or long-term bone sensitivity. *

I have read and understand the risks.

Urethral Prolapse

Your pet has been diagnosed with urethral prolapse. Urethral prolapse is the protrusion of the distal urethral mucosa through the external opening of the penis. This disorder occurs almost exclusively in young male brachycephalic dogs, with English Bulldogs at particularly high risk; however, it has occasionally been described in other breeds. Although the exact cause is unknown, it is thought to be related to abnormal development of the urethra and subsequent increased intraabdominal pressure as a result of labored breathing, dysuria (painful or difficult urination), or sexual excitement. Physical examination reveals a red-purple donut shaped mass of urethral mucosa protruding from the distal end of the penis with many owners reporting bleeding from the prepuce or tip of the penis or licking of the penis related to urination. Treatment recommendations (medical management or surgery) are based on the severity of clinical signs and presence of urinary tract infection, urinary stones, or additional anatomic abnormalities. Medical management may involve treatment of underlying urinary tract infection, urinary bladder inflammation, and/or manual reduction of the prolapsed tissue with placement of a purse-string at the external urethral opening for 5 days. Due to the various underlying factors related to the development of urethral prolapse, recurrence may occur with medical management. Surgery is recommended for patients with excessive hemorrhage, discomfort, or ulceration or necrosis of the prolapsed tissue and for dogs that fail to respond to medical management. The most common surgical interventions are urethral resection and anastomosis (cutting off the affected tissue and suturing the mucosa back together) and urethropexy (tacking of the urethral tissue). As sexual excitement and dyspnea may be predisposing factors, castration and surgical correction of any brachycephalic airway abnormalities are recommended. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2-3 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2-3 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled activity. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. This surgical procedure can have an increased risk of anesthetic complication due to the condition of the patients it is performed on. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Regardless of technique used, intermittent hemorrhage, particularly in association with urination, commonly occurs for 4 to 7 days after surgery. Long-term recurrence of urethral prolapse has been reported in 57% of dogs treated surgically, but occurred less commonly when sedation is utilized postoperatively. Additional potential complications for resection and anastomosis surgery include infection, incisional dehiscence (opening of the incision if resection), and stricture of the urethral opening. *

I have read and understand the risks.

Ventral Bulla Osteotomy (VBO - Middle Ear Surgery): Your pet has been diagnosed with a middle ear infection, tumor, or inflammatory polyp that needs surgical treatment. Nasopharyngeal polyps are benign, fleshy, inflammatory masses found in the nose, nasopharynx (above the soft palate), middle ear, and/or external ear canal. They occur mainly in cats and less frequently in dogs. In dogs, they usually extend into the ear canal rather than the back of the throat. The exact cause of polyps is unknown. They usually occur in younger cats, and littermates can be affected. It is suspected that cats may develop them because of inflammation caused by infectious agents such as respiratory viruses. However, several studies have so far failed to identify an infectious agent. Also, although bacterial infections are commonly associated with polyps, antibiotic therapy alone does not resolve the polyp. Most polyps originate from the lining of the middle ear (tympanic cavity). Polyps can grow up to 2 cm in diameter and usually develop on a stalk. As they grow, they can either burst through the eardrum into the external ear canal or extend through the Eustachian tube, which connects the middle ear to the back of the throat. In a small number of cases, polyps can grow in both directions. They usually only occur on one side; however, in cats, bilateral polyps have been reported in 13%-24% of cases. Clinical signs are dependent on the location of the polyp. Nasopharyngeal polyps typically cause upper respiratory signs associated with breathing obstruction and secondary bacterial infections. Clinical signs may include: sneezing, noisy/labored breathing, difficulty eating/ swallowing, nasal discharge, and change in vocalisation. Polyps affecting the middle ear or external ear canal typically present with middle and external ear infections. Clinical signs may include: head shaking, discharge from the ear canal, pawing or scratching at the ear, abnormal eye movements (nystagmus), head tilt, loss of balance (ataxia), and change in appearance of the eye on the affected side (Horner’s Syndrome). In cases in which a polyp cannot be easily identified, radiographs may be taken and evaluated for soft tissue changes associated with a polyp. More frequently advanced imaging with computed tomography (CT) or magnetic resonance imaging (MRI) is recommended as these techniques provide more information on the location of the polyp and the extent of the disease. Presurgical biopsy of a nasopharyngeal polyp is not generally performed, especially if it is causing significant airway or swallowing obstruction. Evaluation of a removed polyp is recommended to confirm it is benign. Polyps within the external ear canal and nasopharynx can be removed by gentle, steady traction (pulling) on the mass. General anesthesia is necessary. The stalk of the polyp should be removed to reduce the risk of recurrence. Unfortunately, the base of the polyp can be difficult to remove by traction alone, and in many patients the mass will regrow. Therefore, removal of the base of the mass through a ventral bulla osteotomy (opening up the bony middle ear) is often performed to reduce the incidence of recurrence. Several important structures are found along the outside of, or within, the bony structure (“bulla”) that forms the middle ear. Within the bulla, some of the nerves to the eye cross along the inner wall. These nerves are often damaged when the polyp is pulled by traction or when a ventral bulla osteotomy is performed. About 80% of cats will develop Horner’s syndrome after this procedure because of damage to these nerves (Figure 8). In affected cats the third eyelid is elevated, the pupil is constricted and the upper eyelid droops. Horner’s syndrome is usually temporary and does not affect the cat’s vision or behavior. Since the opening to the inner ear is also found in the bulla, post-operatively, some cats may develop balance problems (wobbliness), a head tilt, and rapid uncontrolled movements of their eyes (nystagmus). This condition is usually temporary, but can affect the cat’s well-being whilst it lasts. The lining of the bulla, which is the source of the polyp, must be gently removed to prevent polyp recurrence whilst minimizing damage to vital structures within the bulla. The prognosis for recovery is excellent even in cats that develop Horner’s syndrome or balance problems after surgery, since these signs usually resolve within 4-6 weeks. Traction combined with ventral bulla osteotomy has a low recurrence rate (<2-10%) compared to traction alone (30-50%). I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

My pet is having surgery today on the: *

Left Ear
Right Ear

Recovery: Your pet may need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from scratching or rubbing at the incisions. Most soft tissue surgeries take approximately 2-3 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2-3 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled activity. When not directly supervised, your pet must be confined to a crate. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. This surgical procedure can have an increased risk of anesthetic complication due to the condition of the patients it is performed on. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Complications of ventral osteotomy in cats include Horner's syndrome (drooping of the upper eyelid, constricted pupil with the affected pupil smaller than the other eye, sunken appearance of the eye, and third eyelid elevation where the small, inner eyelid becomes more visible) and development of vestibular signs (head tilt, circling or falling to one side, loss of coordination, difficulty walking or standing, rapid eye movements, nausea, vomiting, and/or lethargy). These are usually the result of either the osteotomy itself or curettage during polyp removal. Signs of Horner's syndrome usually resolve over the course of a few days; however, cats with signs that persist beyond 6 weeks are unlikely to recover fully. Vestibular signs may be iatrogenic, or they can predate the surgery as a result of pressure on the labyrinth (inner ear) structures from accumulation of polyp or mucous material within the tympanic cavity (middle ear). Signs from either cause may resolve. Although the tympanic bulla (bone surrounding the middle ear) does not regenerate after ventral osteotomy the prognosis for resolution of middle ear polyps in cats is reported to be excellent; cats with deafness, however, do not return to hearing function. Additional complications include infection, hemorrhage, and incisional complications. *

I have read and understand the risks.

Vulvoplasty/Episioplasty

Your pet has been diagnosed with an abnormal vulvar conformation, also called recessed vulva or juvenile vulva. This means there is redundant tissue forming skin folds around the vulva that prevent complete elimination of urine and vaginal secretions. The urine retention, or urine pooling may lead to signs of urine dribbling or incontinence. The fluid retention and friction around the folds of tissue lead to bacterial overgrowth, infection and ulceration, leading to chronic urinary tract infections, vaginitis and perivulvar dermatitis. The procedure recommended to address the abnormal conformation and help mitigate the associated signs is a Vulvoplasty. In this procedure the redundant tissue is resected, and the skin edges sutured to eliminate any folds and improve vulvar position. Resolution of clinical signs (i.e. urinary tract infection, dermatitis, vaginitis) will require adjunctive medical treatment to address concurrent infection. Residual urinary incontinence may occur due to causes not addressed by the Vulvoplasty procedure, such as pelvic bladder and vaginal stricture. *

I have read and authorize

Recovery: Your pet will need to wear an E-collar (cone) for at least the first 2 weeks following surgery to protect the incision and prevent him/her from licking or chewing at the incision. Most soft tissue surgeries take approximately 2 weeks for healing to occur. To protect the surgical site and maximize potential healing, your pet will need to be crate rested during this 2 week recovery period. Strict crate rest means no running, jumping, playing with other animals or people, or any uncontrolled off leash activity. In addition, he/she must also be kept off of furniture and stairs during this period. Canine patients may be allowed to go outside to urinate and defecate 3 to 4 times daily, and must always be kept on a leash. When not directly supervised or performing rehabilitation exercises, your pet must be confined to a crate or small room, such as a bathroom or laundry room to prevent him/her from having free access to the house or jumping onto things. Failure to follow these confinement recommendations could result in surgical site complications and the need for additional surgery at an additional cost. *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the above-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. We do not anticipate any complications in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: Intraoperative hemorrhage and incisional complications (infection, dehiscence, and/or seroma (fluid accumulation) formation *

I have read and understand the risks.

NOCITA (bupivacaine liposome injectable suspension) is a long-acting, local anesthetic that provides up to 72 hours of post-operative pain relief by releasing bupivacaine (anesthetic pain relief agent) over time from multivesicular liposomes. Dr. Swanson is happy to provide this additional form of pain medication during surgery for your patient if you would like to do so. Nocita is labeled for single-dose infiltration into the surgical site to provide local postoperative analgesia for cranial cruciate ligament surgery (TPLO, Extracapsular repair, etc) in dogs and as a nerve block in cats for declaw procedures. Like many drugs in the veterinary space that are used commonly, but not specifically labeled for veterinary medical usage, we offer Nocita usage for pain control for our surgical patients off label to be used where deemed appropriate and safe. *

YES - I approve to have Nocita used at the time of surgery on my pet for pain control. I understand that in select instances it may be used off label when deemed safe by Dr. Swanson. Please check with your regular veterinary clinic if it is already included in your estimate. If not included in your original estimate, generally a single dose of Nocita runs $275.
NO - I do not approve Nocita pain control for my pet’s surgery.

I authorize the surgeon (Dr. Swanson) of Midwest Veterinary Surgery, LLC to perform surgery and/or diagnostic procedures on my pet. Dr. Swanson is a board certified small animal surgeon. I understand that there are other small animal board-certified surgeons available in the area. *

I have read and authorize

A cancellation fee of $325 will be charged if the procedure is canceled or rescheduled within 48 hours (not to include Saturday or Sunday as MVS is closed on weekends) of the scheduled surgery date.*

I have read and acknowledge the cancellation fee

Midwest Veterinary Surgery, LLC occasionally features patients on its website, social media sites, and in publications (print or online). With your permission, we may share your pet's picture, video or story. We may mention your pet by name, but never the owner’s name. MVS would be grateful that you'll be helping other pets by educating pet owners, veterinary technicians, and veterinarians. *

I consent to using my pet on social media or website
I do not consent to using my pet on social media or website

I authorize and understand by verbal consent and written consent the above information *

I authorize and consent

Signature *

Clear Signature

Date *

Surgical Release Forms

Midwest Veterinary Surgical Release Forms

Anal Sacculectomy

Anal Sac Tumor Removal

Bone Biopsy

Brachycephalic Airway Surgery

Tail Amputation/Corkscrew Tail Amputation/Caudectomy

Cutaneous (Skin)/Subcutaneous Mass or Tumor Removal

Cystotomy

Cystotomy/Scrotal Urethrostomy - Male Dogs

Digit Amputation

Esophagostomy Tube Placement

External Abdominal Hernia Repair

Exploratory Laparotomy Surgery

Extracapsular Cranial Cruciate Stabilization

Extracapsular Cranial Cruciate Stabilization & Patellar Luxation

Femoral Head and Neck Ostectomy (FHNO)

Fracture Repair

Cholecystectomy/Gallbladder Removal

Implant Removal (Bone Plate/Screws, IM Pin, or Nylon Suture)

Leg Amputation

Liver Surgery

Patella Luxation (MPL/LPL)

Perianal Mass Removal

Perineal Hernia Repair

Perineal Urethrostomy (PU) - Cat

Prophylactic Gastropexy

Salivary Mucocele/Sialocele

Splenectomy

Superficial Digital Flexor Tendon (SDFT) Luxation Repair

Synovial Fluid Aspirate (Joint Tap)

TPLO - Cranial Cruciate Ligament Rupture Stabilization

TPLO & Patellar Luxation

Urethral Prolapse

Vulvoplasty/Episioplasty

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