"*" indicates required fieldsYour Name* First Last Pet's Name* First Last Procedure*Primary Phone*Secondary PhoneOther services (ie vaccines, microchip)IntakeFor cat and dog patients: Your pet should be fasted for surgery. Please note the last time they've eaten the night prior to surgery.*Is the patient on any medications?* Yes NoPlease list medications*Does the patient have any dietary restrictions?* Yes NoPlease list dietary restrictions*If your pet is undergoing a spay surgery, when was their last heat cycle?Do you have any other questions related to surgery or anesthesia for the doctor?Please carefully read and acknowledge the following:*I, the undersigned, hereby confirm that I am the legal owner/agent of the animal described above and I am authorizing the surgical/treatment procedure(s) listed above to be performed on my pet. I consent to the administration of such analgesics, sedatives, tranquilizer, anesthetics or other medications as may be deemed necessary by the attending veterinarian(s). The nature of these procedures has been explained to me and I understand what will be done. I have also been informed that there are risks and complications associated with any procedure or operation of this type, even in healthy animals. They have been explained to me as well. I further understand that during the course of the procedure or operation unforeseen conditions may arise which may necessitate performance of additional procedures and I will not hold Shelburne Veterinary Hospital or its staff responsible for any unforeseeable results.Please carefully read and acknowledge the following:*I also understand that conditions not known may make it advisable that additional treatment, procedures or surgery be performed on my pet. I understand that every reasonable effort will be made to contact me. Until I can be contacted, I hereby authorize the staff of Shelburne Veterinary Hospital to perform any reasonable treatment, procedure or care as deemed necessary by the attending veterinarian(s). For patients undergoing anesthesia it’s appropriate to decide in advance whether aggressive measures of resuscitation (CPR) will be employed if needed. DNR means “Do Not Resuscitate”. This is a decision that resuscitation (CPR) is not to be performed if the pet stops breathing, has no heartbeat, collapses or becomes unconscious. Resuscitation (CPR) of a collapsed or unconscious patient is tailored to meet the needs of the individual but may include any or all of the following: Establishing an airway via insertion of an endotracheal tube and administration of oxygen or medications through the tube. Establishing intravenous access via insertion of an intravenous catheter. Administration of fluids and injectable medications through the catheter. Chest compressions. Intracardiac delivery of injectable medications Animals that have survived cardiopulmonary arrest and have been successfully resuscitation (CPR) are extremely critical and unstable. Management of the post-arrest patient requires vigilant monitoring and the technical expertise of dedicated critical care personnel at Burlington and Emergency Veterinary Specialists.Please read and make your selection below:* BLS – Should my pet suffer respiratory or cardiac arrest, I DO wish the staff of the Shelburne Veterinary Hospital to perform CPR (Resuscitation. I understand that my pet may not respond to CPR or may respond initially and then suffer another arrest later. I understand that my pet may die despite CPR. I understand that if my pet survives because of CPR, he/she may have brain damage. DNR – I DO NOT want CPR performed on my pet. I understand that if my pet stops breathing and/or is/her heart stops beating that my pet will die unless CPR is performed. I elect to have DNR (Do Not Resuscitate) orders placed on my pet’s record should my pet suffer respiratory or cardiac arrest.Please carefully read and acknowledge the following:*I have reviewed an estimate for the procedure. I fully understand that this is an estimate only. Shelburne Veterinary Hospital makes every effort to remain within the estimate range given. I acknowledge that I will bear full financial responsibility for any and all costs incurred for the surgical procedure, care and treatment of my pet and I am aware that all outstanding accounts are payable in full when services are rendered.Signature*Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
