We are now located at 7299 US-52, New Palestine, IN 46163
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317-375-1737
317-375-1737
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Mass and General Surgical Consent
Mass and General Surgical Consent
Company
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Pet Owner Information
Client's Name:
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First Name
Last Name
Pet's Name
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First
Primary Phone Number
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Primary Email
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Procedure to be preformed?
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If your pet is having a mass removed, please complete this section. Please indicate location and number of mass(es) to be removed:
(Required)
Please be as descriptive as possible. Use the image below to help identify location(s).
Pre-Anesthetic Information and Diagnostics
Please fill out the questions below in as much detail as possible.
Is your pet on any medications?
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Medication name
Amount administered
Time of last dose
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Put NONE in medication name box if pet is not on medications.
If your pet requires medications for anxiety or reactivity for their appointment, please give one dose the night before their appointment and one dose two hours before their appointment.
Please confirm what time you gave your pet’s medications
PM dose given:
Yes
No
Time medication administered:
Hours
:
Minutes
AM dose given:
Yes
No
Time medication administered:
Hours
:
Minutes
Please confirm which medication(s) you gave your pet:
Gabapentin
Trazadone
Acepromazine
Select all that apply
When was your pet's last meal?
(Required)
Type of food
Feeding amount
Time of feeding
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Pre-Anesthetic Bloodwork and Tests: Procedures requiring anesthesia are always associated with a certain amount of risk, whether the patient is a person or a pet. Like you, we want to minimize that risk as much as possible. General anesthesia has become safer in more recent years as new medications and monitoring equipment becomes available, however, some conditions are not evident on physical exam. To better ensure your pet’s safety during anesthesia, the following pre-anesthetic tests are strongly encouraged:
(Required)
Pre-anesthetic Panel, $110, recommended for young and healthy pets (mini-chemistry, complete blood count)
Pre-Anesthetic Panel 2, $154.00, required for geriatric or sick pets (large chemistry with electrolytes, complete blood count)
My pet has already had the required panel to proceed with surgery.
Histopathology: Histopathology is the evaluation of whole tissues and is performed on surgically removed lumps. The mass is thinly sliced and sections are evaluated by a Veterinary pathologist. This gives a diagnosis, prognosis and can determine if the entire tumor has been removed. We recommend pathology on all removed tissues to better guide you in caring for your pet moving forward. *
(Required)
Yes, I would like to send the mass(es) for biopsy ($250.03 + depending on number/size)
No, I decline biopsy of the mass. I understand that a diagnosis cannot be made based upon visual examination alone.
Pain Medications
Pain medication is required after oral surgery. The attending veterinarian will assess your pet's anticipated pain level and administer and prescribe appropriate medication. Pain medication can range from $35.00-$100.00 depending on your pet's weight and expected pain level.
Additional/Optional Treatments
In order to ensure safety of our patients and staff, we require up to date vaccinations for all hospitalized patients. If your pet does not have documentation for all vaccinations, they will be administered at the time of their visit. In addition, if any fleas are found, your pet will be treated. By signing below, you indicate your understanding that vaccinations or flea treatments required will be at your expense and may exceed the original provided estimate.
Indicate any optional treatments below.
Pedicure (Nail trim - Courtesy while under anesthesia)
Microchip $77
Anal Gland Expression $29.70
Ear Cleaning $29.70
Heartworm &Tick-Borne Disease Testing ($73.73) or HW/FeLV/FIV Test ($92.31)
Surgical Laser Fee $74.90 (For oral surgery, if indicated. Laser surgery results in less bleeding, decreased pain, reduced risk of infection, and faster recovery after surgery)
I decline all additional treatments.
General Release
I understand that I am leaving my pet in the care of Indy Paws Veterinary Hospital (IPVH) for care and treatment. I have been informed of the procedure my pet is having performed and am aware that the goal at Indy Paws Veterinary Hospital is to practice the highest quality of medical care. Understanding this, I know that IPVH will do everything possible to treat my pet with care and respect while in their care. There are some medical situations that can occur that are beyond the Hospital's control and all possible efforts and resuscitation will be made in case of a medical emergency. I understand that Indy Paws Veterinary Hospital will not be held responsible for an unexpected death of a patient. My pet will be considered abandoned if Indy Paws Veterinary Hospital has not heard from me within 5 days of the expected date of discharge. The hospital is authorized to manage my pet however they deem best if this should occur. I further understand that no guarantee of successful treatment can be made.
In case of emergency, best phone number to reach you during the day of the procedure:
(Required)
Phone number
Emergency contact information during the day of procedure.
Name
Phone number
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In the event we are unable to reach you, please provide an emergency contact.
In the event that your pet should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of his or her status?
(Required)
Yes, proceed with resuscitation if needed.
No, do not perform CPR in the case of arrest.
Policies and Release
I will ensure my pet urinates and/or defecates before drop off. Accidents in the hospital can increase the risk of infection and ensuring empty bowels can reduce this risk. *
(Required)
I agree
Financial responsibility and obligations
I agree
I certify that I understand this release and furthermore assume full financial responsibility of all charges accrued. I am agreeing to all items listed above and the estimated costs of the procedure as provided. I understand that the initial costs are estimated and are subject to change. If there is anticipation that a change to estimated services is significant (>10%), Indy Paws will make every effort to reach out to discuss prior to proceeding.
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