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Surgical Authorization Form

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Please complete our surgical authorization form before your pet's procedure.

I, the undersigned, certify that I am the owner or authorized agent of this pet, and I authorize the veterinarians and support staff at Arbor View Animal Hospital to perform my pet’s scheduled surgery or sedated procedure.

1. Authorization of Surgery/Procedure:

I authorize Arbor View Animal Hospital to perform the diagnostic, therapeutic, surgical and anesthetic procedures advisable for the treatment and maintenance of my pet’s health. I understand that during the performance of these procedures unforeseen conditions may be revealed that necessitate additional services, or an extension of the procedures described above. I consent to the performance of such procedures as are deemed necessary in the veterinarian’s professional judgment and accept responsibility for all charges incurred in the care and treatment of this animal.

2. Anesthesia:

I acknowledge that general anesthesia will be administered to my pet during the procedure. I understand that there are inherent risks associated with anesthesia, and I have read the link below regarding these risks.

https://arborviewah.com/potential-risks-of-general-anesthesia-and-sedation/

3. Contact Person:

So we can efficiently communicate with you after your pets surgery/sedated procedure please provide a name and number of the person picking up your pet.

Name: *

the If preferences

Phone Number: *

4. Emergency Contact:

Please provide an emergency contact who can make medical and financial decisions on your behalf if we are unable to reach the contact person listed at the phone number provided during a medical emergency.

Name: *

Phone Number: *

5. Estimates & Fees:

I have been provided with an estimate of the costs associated for my pet’s surgery and related care. I understand that actual charges may vary depending on the complexity of the procedure and any unforeseen circumstances, and I agree to pay for all services rendered. Payment in full must be made when services are rendered. We accept Cash, Visa, Mastercard, Discover, CareCredit, and Scratchpay. Estimates are valid for 30 days. If you need an updated estimate, please text or call our office at 219-762-7267.

Thank you for trusting us with your pet's dental care. We want to ensure you understand that while we provide the most accurate estimate possible before performing dental procedures, the full extent of dental disease can only be determined once we have cleaned and thoroughly examined your pet's teeth, as well as reviewed their dental CT imaging.

Sometimes, there may be more diseased teeth than initially anticipated, which could require additional extractions. In such cases, the overall cost may be higher than the original estimate.

In order to reduce the amount of time that your pet is under anesthesia, we ask that you help us plan for any unforeseen extractions that would affect the total cost of their procedure. If the cost of my pets’ dental extraction(s) exceeds the estimate, I request that you:

Call with an updated estimate. (Please make sure you are available at the number listed above. Your pet will be under anesthesia when we call so we will need to keep the conversation brief and if we are not able to get ahold of you, we will not be able to extract the diseased teeth during this procedure)
Extract the additional diseased teeth without calling up to the additional cost entered below. If the additional extractions would exceed the estimate by more than the number below, call first. (Please make sure you are available at the number listed above. Your pet will be under anesthesia when we call so we will need to keep the conversation brief and if we are not able to get ahold of you, we will not be able to extract the diseased teeth during this procedure)
Extract the additional diseased teeth without calling no matter the additional cost.
N/A (my pet is not having a dental procedure)

If you selected option 2 in the above question, what is the maximum additional cost that you are comfortable with us proceeding without calling first? (this is additional cost, not total estimate cost) If you chose options 1, 3 or 4, write N/A.

6. Pain Management:

I understand that pain management options will be provided depending on the surgery/procedure being done on my pet, and I consent to their use. As of January 1, 2021, Indiana law requires veterinarians to check a pet owner's INSPECT record before prescribing any opioid or benzodiazepine for pain management. To comply with this regulation, we must collect the pet owner's legal name and date of birth. If this information is not provided, your pet’s procedure may be canceled if the veterinarian determines that adequate pain management cannot be achieved without the use of a controlled substance.

Please provide the pet owner's Legal Name *

Please provide the pet owner's Date of Birth *

7. Microchip:

Microchips are not tracking devices, but they provide a permanent form of identification that can help reunite you with your pet if they become lost. When scanned, the microchip provides your contact information, making it easier for shelters or veterinarians to return your pet to you.

If your pet does not already have a microchip, would you like us to place a microchip during your pets procedure. The additional cost is $77 and includes the registration. *

8. Bloodwork:

Pre-anesthetic bloodwork is an important step in ensuring the safety of your pet before any surgical procedure or anesthesia. It helps us assess your pet’s overall health and identify any underlying conditions, such as liver or kidney problems, infections, or clotting disorders, that may not be visible during a routine physical exam. This allows us to adjust anesthesia protocols to minimize risks and provide the best care for your pet during their procedure. This bloodwork should be done within 30 days and at least 1 week before the procedure. It is required for any pet 3 years or older and recommended for pets younger than 3.

If your pet is younger than 3 years, would you like us to run the pre-anesthetic bloodwork panel? (Must be completed at least 1 week prior to your pet's procedure)

Yes (please text or call to schedule a tech apt)
No
My pet is older than 3 years and has completed the required bloodwork.
My pet is older than 3 years and has not completed the required bloodwork. (Please text or call to schedule a tech apt)

9. Medications:

List the medications that your pet is currently taking. You can give your pet their medications as prescribed with a tablespoon or smaller amount of food the morning of your pets surgery/procedure.

10. CPR:

Please help us provide the best care for your pet by making important decisions in advance. In the event of a cardiac or respiratory emergency, we will make every effort to contact you immediately. However, in critical situations, every second matters, and initiating life-saving measures such as CPR without delay can make the difference between life and death.

Because we may not always be able to reach you before taking action, we ask that you indicate your preferences for emergency care in advance:

I request CPR including artificial ventilation and external cardiac assistance (CPR) be preformed on my pet. I am aware of the fees and risks associated with these services being performed. The minimum cost for CPR is $150, and depending on your pet's specific needs the price may vary. CPR means we do everything we can to resucitate your pet and has a 6-8% success rate. Due to the nature of performing CPR, there is risk of broken ribs and organ injury and not all patients return with 100% neuro functionality.
I hereby request that in the event my pet's heart and/or breathing should stop, no attempt will be made to resuscitate the pet.

11. Fleas:

To ensure a clean and comfortable environment for all our patients, our hospital policy requires that any pet found with fleas or flea dirt be treated with Capstar, a fast-acting oral medication that eliminates fleas within 24 hours. This treatment will be administered at the owner's expense at a cost of $13 per tablet. For ongoing flea control, we strongly recommend a monthly flea prevention, such as NexGard, to effectively manage and prevent future infestations.

12. Unforeseen Complications:

I understand that in the unlikely event of my pet passing during the surgical procedure, I will remain responsible for the cost of the surgery that was performed.

13. Fasting and Appointment Instruction:

Our staff will call you the day before your pet’s procedure to provide fasting instructions and schedule an admission appointment. It is essential that you arrive on time for this appointment to ensure your pet’s procedure can proceed as scheduled. Late arrivals may result in their procedure being rescheduled.

Name: *

Signature *

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Caring medicine for all animals.

If you live in Valparaiso or the surrounding area and need a trusted veterinarian to care for your pets – look no further. Arbor View Hospital Team is a licensed IN veterinarian, treating all types of pets. Your pets’ health and wellbeing are very important to us, and we take every possible measure to give your animals the care they deserve.

Location

244 West U.S. Highway 6
Valparaiso, IN 46385
Click here for directions.

Hours

Monday: 8:00am – 8:00pm
Tuesday: 8:00am – 8:00pm
Wednesday: 8:00am – 6:00pm
Thursday: 8:00am – 8:00pm
Friday: 8:00am – 6:00pm
Saturday: 8:00am – 1:00pm
Sunday: Closed

Contact Info

Phone: (219) 762-7267
Fax: (219) 763-9425
Email: arborviewah@gmail.com

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