Necessary for release of controlled drugs Contact info
For your pet's safety, COR requires the name and phone number of someone who can be contacted without delay during your pet's hospitalization in case of emergency. This person, if not the owner, must be authorized to make medical and financial decisions for your pet if contacted. By entering an authorized person here, you, the owner, consent to their ability to make these types of decisions by phone during your pet's hospitalization. Contact Person(s) must be able to be reached immediately at the given phone number throughout the day of the procedure, in case of emergency.
Information about the Procedure Your pet will have an elective orthopedic surgery today. This procedure requires general anesthesia to prevent pain. Your pet will have an intravenous (IV) catheter placed for administration of medications, requiring a shaved area (usually on a front leg). Your pet will be given medications as a sedative and to induce anesthesia (make them sleep), and an endotracheal (ET) tube placed in their trachea to supply oxygen and anesthetic gas. Pain medications will be given as well. A large area on your pet's coat will be shaved to properly prepare the surgical area. Additional information specific to your pet’s condition was discussed with you prior to surgery and you acknowledge that you understand the procedure(s) that will be performed on your pet.
If there are any other issues or concerns that you would like addressed, please state below:
Pre-Procedure Instructions:
It is vital for your pet's safety and well-being that you follow these instructions. Please contact us if you have concerns about these instructions prior to your scheduled surgery date.
Fasting:
For the safety and well-being of your pet, he/she must be fasted prior to anesthesia/sedation. Your pet should not be given food or treats of any kind after 11pm the night before the procedure. Water may be offered as usual until coming into the hospital.
Pre-Anesthetic Blood Testing:
The veterinarians at COR require performing pre-anesthetic blood testing prior to any anesthetic procedure. This blood testing can allow identification of pre-existing health issues that could cause increased risk of complications during or after the procedure. The testing we recommend for your pet varies based on your pet's age and current health status.
Pre-Anesthetic Blood Testing Choice:
Medications & Supplements:
If your pet is on any medications, supplements or special diet at this time, please contact COR to determine whether you should administer any medications the day of your pet's procedure. Please bring any medications to the check-in appointment in case the veterinarian determines that your pet should receive dosing while hospitalized.
Advanced Directive:
At COR, the safety, well-being and comfort of patients is valued above all else. During the procedures detailed on this form, unforeseen conditions may arise that necessitate the performance of additional procedures or a change in the current treatment plan. In the case of life-threatening complications during your pet's stay, we will perform emergency treatments and procedures as deemed necessary, up to and including Cardio-Pulmonary Resuscitation (CPR) unless you specifically decline such actions. COR will make reasonable effort to contact the authorized contact person(s) listed on this form prior to any altered treatment plan or additional procedures. COR requires an advanced directive so that they are able to follow your wishes if unexpected circumstances arise and they are not able to reach the authorized contact person(s).
Please select an Advanced Directive Option:
Option 1: I authorize COR to perform any recommended and emergency procedures during my pet's hospitalization if they are unable to reach my authorized contact person(s) listed on this form. I accept responsibility for any result in additional charges.
Option 2: I authorize only emergency and/or lifesaving procedures to be performed without the consent of myself or my authorized contact person(s). By selecting this option, I understand that the veterinarian may recommend a future visit and/or separate procedure to complete appropriate non-emergency medical or surgical care for my pet, at my own additional expense. I accept responsibility for any additional charges resulting from emergency procedures.
Option 3: I decline any and all procedures not explicitly documented in this consent OR agreed to by myself or my authorized contact person(s) during my pet's stay at COR. This is a Do Not Resuscitate order and your pet will not receive even lifesaving emergency care if you choose this option.​
Advanced Directive Option
Consent for Procedure:
The nature of these procedures or operations has been explained to me, and I understand what will be done. I have also been informed that there are certain risks and complications associated with any sedation, anesthesia, operation or procedure. I understand the benefits and risks of this procedure, as well as the expected recovery and prognosis for this procedure. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that necessitate the performance of additional procedures. I am aware that the practice of veterinary medicine is not an exact science, and I acknowledge that no guarantees have been made to me concerning the results of this procedure.
I authorize COR to perform the procedure(s) in this consent.
Allergies:
Please list any and all allergies that the patient has including food, medications, and all else below.
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Overnight Care:
I understand that COR does not provide intensive care during the night. Should your pet require overnight care, it would be transferred to a local emergency practice like TrueVet (707-787-5340) in Petaluma or Animal Care Center (707-584-5353) in Rohnert Park.
Abandonment of Pet:
If I do not pick up my pet within 48 hours after its procedure, then I relinquish all claims to the pet, and the veterinarians or agents of the clinic may make whatever decision necessary concerning the disposition of the pet. I understand that in such circumstances I am still responsible for paying all costs of services provided.
Estimation of Cost:
I understand that I have the right to request a verbal or written cost estimate for any procedures to be performed by COR at any time. COR tries to be open and forthcoming with cost estimates and updating such estimates throughout the course of treatment as needed, but it is not always possible to be precise with estimates of medical care. Costs can vary for many reasons, including, but not limited to, patient age, size, weight, health status, response to medications or treatments, and medical complications. I understand this and accept responsibility for charges incurred throughout the hospitalization and treatment of my pet. A 50% deposit is required to schedule the surgery. Payment in full is expected at the time services are rendered, and no later than at the time of discharge.
Contact the Clinic If Your Pet Shows Symptoms Before Surgery
If a pet shows any signs of coughing, sneezing, vomiting, or diarrhea within 24 hours prior to their scheduled surgery, it is crucial to contact the clinic immediately. These symptoms need to be addressed by consulting with a veterinarian prior to the surgery. By clicking the box below, you understand and are acknowledging these terms.
Emergency Services & Questions
Please be advised that our clinic does not provide emergency services for small animals. If your pet requires urgent medical attention, we recommend contacting a local small animal hospital such as TrueVet in Petaluma or the Animal Care Center in Rohnert Park. For any surgical-related questions, please call our clinic at 707-721-4402 ext 3 for canine inquiries. For payment inquiries, please contact our front office at ext 2.
Consent for Electronic:
Signature By selecting "I agree", you are agreeing to sign this consent form electronically (E-signature). You agree that your E-signature is the legal equivalent of your actual signature on this agreement. You also agree that no certification authority or other third party verification is necessary to validate your E-signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E signature.
Signature for Consent:
By signing below, I am agreeing that: I am the owner or authorized agent of the owner of the animal being presented and have the authority to execute this consent. I have read and understand the information contained in this form and that all of the information provided in this multi-page document is accurate and true.
I agree to electronically sign this document.
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