Surgery Form 3 Boarding Anesthesia and Lab Consent Form - Rogue Equine & Companion Animal Clinic

Today's Date*

Owners First and Last Names*

First Last

Emergency Phone Number*

Please provide a phone number(s) where you may be reached at ALL times while your animal is in our care.

Your animal's name?*

Your animal's age?*

Sex*

Male
Male Neutered
Female
Female Spayed

Your animal's species?*

Your animal's breed?*

Your animal's approximate weight?*

Procedure to be performed:*

Please state the procedure recommended to you by the veterinarian. Noting this incorrectly may cause delays. If you are unclear, please call (541)826-9001 and ask to speak to the veterinarian recommending the procedure.

Any unusual, dangerous or peculiar behaviors we should know?*

Please disclose any behaviors we should know about, those that are particularly dangerous to themselves or humans. This is important for the safety of your animal.

no
yes
unknown

Is your animal currently on any medication?*

If your animal is on medication, and should remain so while with us, please list ALL types and when last given.

NO
YES, LISTED BELOW

Known medical issue(s)?*

Please note any known medical issues your animal may have in addition to the reason your animal is staying with us.

Any history of allergies to medications or issues with sedative or anesthetics?*

Though your animal may not be staying for a medical or surgical procedure, it is still important for us to know if there are any know medication issues or allergies.

No
Yes
Unknown

Is your animal insured?*

Please select all that apply.

Major Medical
Mortality
Loss of Use
None

Preferred food if not NPO while boarding

Please list here your preferred food choices. We will do our best to accommodate. If we cannot do so, we will notify you as soon as possible. Please send along special feed that may not be readily available to us.

Pre-anesthetic testing - please select one choice*

If your animal is scheduled for a procedure that requires anesthesia. Pre-anesthetic testing is recommended for their health and safety. Before placing your animal under anesthesia, the veterinarian will perform a complete physical examination to identify any existing medical conditions that may complicate the procedure and compromise their health. A physical exam alone will not identity all potential health problems, thus we strongly recommend pre-anesthetic bloodwork. While pre-anesthetic testing does not guarantee the absence of anesthetics complications, the risk of complications is greatly reduced and medical conditions may be discovered which may necessitate medical treatment.

First Choice - Profile #1 -Recommended for healthy patients under 7 years of age. Includes BUN (kidney), ALP (liver), Total Protein (hydration), Creatinine (kidney), ALT (liver) and Blood Glucose
Second Choice - Profile #2 -Recommended for healthy patients over 7 years of age. Includes BUN (kidney), ALP (liver), Total Protein (hydration), Creatinine (kidney), ALT (liver), Blood Glucose, Amylase (pancreas), Phosphorus (kidney), Bilirubin (liver), Albumin ([protein), Globulin (protein), Calcium, Sodium and Potassium.
Third Choice - Profile #3 -Recommended for healthy patients over 7 years of age. Includes BUN (kidney), ALP (liver), Total Protein (hydration), Creatinine (kidney), ALT (liver), Blood Glucose, Amylase (pancreas), Phosphorus (kidney), Bilirubin (liver), Albumin ([protein), Globulin (protein), Calcium, Sodium and Potassium plus Complete Blood Cell Count.ice
I DECLINE the recommended testing at this time and request the procedure be carried out without pre-anesthetic testing. I understand the risks involved with putting my pet under anesthesia without pre-anesthetic testing and agree not to hold Rogue Equine and Companion Animal responsible if complications occur.

Authorization and Risk Assessment:*

I authorize anesthesia and surgery for my animal. The nature and risks of this procedure(s) have been explained to me. I understand that some risks exist with anesthesia and/or surgery. My signature on this consent form indicates that any questions have been answered to my satisfaction.
I authorize Rogue Equine and Companion Animal Clinic to perform additional diagnostic, treatment, or procedure(s) deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. While Rogue Equine and Companion Animal Clinic provides the highest quality of anesthetic monitoring and surgical services, I understand that there are rare complications associated with any anesthetic or surgical procedure. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures.
I fully understand these risks and understand that the veterinarian and hospital staff will try to minimize such risks. I will not hold Rogue Equine and Companion Animal Clinic, veterinarians, or any staff member liable for any complications that may arise.
I HAVE READ AND FULLY UNDERSTAND THIS SURGERY AND ANESTHESIA CONSENT FORM.

I AGREE AND CONSENT

AGREE AND CONSENT TO INITIAL EXAM*

Upon entry for boarding or hospitalization, you agree to an initial exam performed by a staff veterinarian or technician. Any abnormalities or concerns will be reported to you as soon as reasonably possible. Naturally, this exam will take place anyway in the case of hospitalization for a medical condition or surgery. Regardless, and exam will take place even for a boarding situation, and for which there may be a fee applied in addition to boarding. By checking this box, you agree to the exam and the fee.

I agree and provide my consent

HOSPITAL STAFFING, CARE AND LIABILITY*

Rogue Equine Hospital and Rogue Animal Clinic (or any DBA) is not always staffed 24 hours, 7 days per week. When animals are boarded or hospitalized, video monitoring and frequent inspections are made to ensure your animal's safety and care. Being animals, things do happen from time to time and are out of anyones control. We take every precaution to ensure the health and safety of your animal for which you have entrusted us. We will notify you immediately upon identification of a problem. We require your consent to take emergency action to prevent further injury or damage, to protect life and limbs and until such time we can communicate the situation and make further decisions with you and as directed by you. We will not perform elective procedures unless explicitly acknowledged by and approved by you.
In addition, we need your explicit release of liability directed to all veterinarians, employees (including their dependents and heirs) of Rogue Equine Hospital and Rogue Animal Clinic (and all DBA's). By selecting this checkbox, you are agreeing to the above, consenting and releasing of liability as noted above.

I agree

Signature*

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Phone

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Surgery Form 3 Boarding, Anesthesia and Lab Consent Form