Pre-Surgical Form – Butler Veterinary Associates and Emergency Center

Please help us prepare for your pet’s upcoming surgery by submitting this pre-surgical form for your dog’s spay. We have two options for you, you can download a pdf form here and email, fax, or bring to the office. Otherwise, please fill out the online form below for your convince.

Canine Spay Check-in Form

Pre-surgical

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Emergency Contact #*
Date of Planned Surgery*
MM slash DD slash YYYY
Patient's Name*
First
History
Where does your pet spend most of his/her time?*
- Indoor
- Outdoor
- Indoor/Outdoor about equal
Has your pet ever had a seizure?*
- No
- Yes, if so, please describe
Tell us about you're pet's Seizure*

Date, time, nature of the event
Has your pet ever had a vaccine reaction?*
- No
- Yes, if so, please describe
Tell us about you're pet's vaccine reaction*

Date, time, nature of the event
Has your pet ever had an allergic reaction?*
- No
- Yes, if so, please describe
Tell us about you're pet's allergic reaction*

Date, time, nature of the event
Has your pet ever had surgery before?*
- No
- Yes, if so, please describe
Tell us about you're pet's surgery*

Date, time, nature of the event
Has your pet ever had a heat cycle?*
- No
- Yes, if so, when was the last heat
When was you're pet's heat?*
Is there any chance that your pet has been bred or is pregnant?*
- No
- Yes
Was food withheld after 10 pm the night before?*
- No
- Yes
Surgical Procedure
Does your pet have any baby teeth that need extracted?*
- No
- Yes
Does your pet have any hernias that need repaired?*
- No
- Yes
Does your pet have any dewclaws that you want removed?*
- No
- Yes
Are there any additional procedures?*
- No
- Yes, if so, please describe
Additional Procedures requested
Would you like a Home Again microchip inserted today?*
- No
- Yes
Pre-surgical bloodwork is recommended on all patients going under anesthesia. Would you like bloodwork performed prior to surgery?*
- No
- Yes, is so, please let us know status [next question]
Has bloodwork been done?*
- No, still needs done prior to surgery
- Yes, already done
Disclosures
Potential Complications of Anesthesia

Anesthesia is a vital part of your pet’s care, but it also comes with risks including blindness, deafness, brain damage, aspiration pneumonia and other potential problems (i.e. organ damage and death). Underlying conditions (kidney/liver disease, intestinal blockage, liver disease, trauma and internal bleeding, etc.) can increase the risks, but we closely monitor blood pressure, heart rate and respiratory rate and intervene when necessary to try to prevent any complications. The following are rare potential complications that can arise with spaying our dog or cat.
- Incisional Dehiscence/ Infection
  - An incision is made through the skin, fat layer, and abdominal wall to remove the uterus. This incision is closed with multiple layers of internal sutures (+/- external sutures). Excessive activity or licking at the incision can cause the incision to become infected and affect the integrity of the sutures resulting in opening of the incision. An additional surgery may be necessary to correct the life threatening infected incision or dehiscence.
- Ligature slippage
  - The vessels that provide the blood supply to the ovaries and the uterus are either ligated (tied off) with suture or cauterized during the spay procedure. Even though each ligature or suture is checked multiple times during surgery, there is a small risk that the ligature may slip off the end of the vessel causing internal bleeding.
- Ovarian remnant/Stump pyometra
  - An ovarian remnant occurs when a small portion of the ovarian tissue remains in the abdomen due to ectopic tissue or incomplete removal of the ovarian tissue. This can occur if the tissue can produce hormones and cause another heat cycle, but they are not able to get pregnant. This is a higher risk in obese or older animals. Another surgery would be necessary during a heat cycle to find the remaining portion of the ovary. If an ovarian remnant is present to produce hormones, a stump pyometra (an infection of the small portion of uterus remaining) can occur.
- Urinary Incontinence
  - Urinary incontinence may occur in 4-20% of spayed female dogs usually within 3 years of the procedure. This condition is caused by multiple factors relating to the lack of estrogen produced by the ovaries. This can usually be controlled with medication.
- Cranial Cruciate Ligament Rupture
  - Spaying of large breed dogs in particular at a young age causes delayed closure of the physis or growth plates resulting in longer bones and steeper angles within the joints; consequently, a higher number of cranial cruciate ligament ruptures are seen.
If your pet requires hospitalization overnight:

Overnight Stay. Although there is not a doctor present from 10 p.m. to 8 a.m., there are trained staff to treat and monitor your pet overnight onsite. If any drastic changes occur, the emergency doctor will be called to discuss treatment and possibly return to the hospital.

Overnight communication. Our phones are turned off from 10 p.m. to 8 a.m. the next morning, Mon thru Friday and 4pm to 8am Saturday, Sunday, and holidays. No news is good news overnight. If here is an emergency that involves your pet, you will be called by the technician or the doctor depending on the circumstance. You will be provided with an update the following morning after the morning doctor examines your pet (usually between 8 and 10 a.m.).

Intravenous Fluids. Usually your pet is placed on IV fluids when in the hospital to treat dehydration or to provide a way to medicate your pet. In rare occurrences, too much fluid can be administered that can build up in the lungs causing difficulty breathing, but they are monitored closely to prevent complications caused by excess fluids.
Consent Section
I, the undersigned owner or agent of the owner of the pet identified above, certify that I am eighteen years of age or over and authorize the veterinarian(s) at this practice to perform the above procedure(s). I understand that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:
- The reasonable medical treatment options for my pet.
- Sufficient details of the procedures to understand what will be performed.
- How fully my pet will recover and how long it will take.
- The most common and serious complications.
- The length and type of the follow-up care and home restraint required.
- The estimate of the fees for all services.
While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. I also understand that my pet’s medical condition may change for better or worse and the attending veterinarian(s) may add or change treatments to fit the needs of my pet’s care as long as it falls within the guidelines of the estimate that was provided to me.

I assume financial responsibility for the services rendered and provide payment via cash, credit card (notAmerican Express), or check at the time my pet is discharged from the hospital. Should unexpected lifesaving emergency care be required I elect one of the following:
Election #1 [Resuscitation]*
- I Agree
- I Do Not Agree [DNR choice will appear)
Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency drugs, or other heroic interventions, I request the veterinarian(s) at this hospital pursue such medical care. Having requested such emergency procedures, I agree to be held responsible for a minimum resuscitation fee of $325 to pay for the services performed while staff members pursue treatment and try to reach me for further directions. Regardless of my pet’s survival, I agree to pay this fee in addition to the other fees already identified by the practice and agreed upon by me. I accept that if the hospital staff is unable to reach me within 15 minutes after the initiation of CPR procedures, and after exercising reasonable medical judgment, determine that there appears to be virtually no hope for medical success, they will cease further CPR procedures. I understand that despite the best efforts of the doctors and staff at this facility, even the most successful CPR that restores my pet’s life may not allow my pet to regain his/her normal mental and physical health and thus, may leave him/her as an invalid.
Election #2 [DNR]*
- I Agree
- I Do Not Agree
I elect NOT to have the medical team pursue any lifesaving procedures. No person shall attempt to resuscitate my pet should my pet’s heart stop and or breathing stop. DO NOT RESUSCITATE (DNR). Instead, I request that the attending veterinarian assist my pet in dying in a peaceful manner.
Signature of Owner or Agent*
In the event my pet is hospitalized beyond the first day at this facility, I understand that veterinary care during nighttime hours is provided at the discretion of the attending veterinarian, who is not present at the facility from 10 p.m. to 8 am. I am aware that there are other emergency facilities that have a veterinarian present at all times and have the option to transfer to one of these facilities. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made. I have read and understand the nature of the above procedures and give my consent to proceed.

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Canine Spay Check-in Form

History

Surgical Procedure

Disclosures

If your pet requires hospitalization overnight:

Consent Section