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High-Risk Surgery Form

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High-Risk Surgery Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

You may use the PDF version by clicking the DOWNLOAD FORM button and then completing the printed form by hand. Please bring the completed PDF form with you for your pet’s first appointment.

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In the medical opinion of the doctors of the Accessible Veterinary Care, LLC your pet is considered at increased risk for anesthesia and surgery. Risks from surgery include, but are not limited to, surgical, anesthetic, or post-surgical complications, including death. Some medical conditions (such as heart conditions) can be worsened with anesthesia and results may not be apparent immediately. Your animal could be at increased risk due to any of the
following:

• Medical condition or illness (respiratory infection, GI concerns, infections)
• Physical exam finding (heart murmur, fever, poor condition, brachycephalic)
• Age (over 7 years old in general)
• Late-term pregnancy, recent post-partum
• Feral Feline – Your Pet may not receive a pre-operative physical exam
• Aggressive Pet – Your Pet may not receive a pre-operative physical exam
• Other

It is the recommendation of the AVC that your animal receives a diagnostic work-up and medical evaluation/care PRIOR to undergoing surgery. Diagnostic work-up may include:
a physical exam, ultrasound, ECG, radiographs, and/or blood work. Understanding fully all of the above, I choose to have ’s procedure performed at the Accessible Veterinary Care (AVC) and accept all risks associated with this decision. I will not hold Accessible Veterinary Care (AVC) or any of its employees or associates liable for any consequences associated with this procedure.

The final decision as to whether or not surgery is performed is up to the doctor on the case. If the doctor feels the animal is at severe risk, AVC has the right to refuse or stop surgery at any time. Owners will be charged for the procedure once the animal is anesthetized. If there are surgical or post-surgical complications and the doctor feels it is necessary for the animal to receive additional care the animal will be transferred to the Emergency Clinic. It is up to the discretion of the doctor whether the animal needs overnight care, and by signing this waiver you agree to pay for and receive the recommended care. A credit card or deposit will be required at the Emergency Clinic. *

I have read and understand the above information.

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High-Risk Surgery Form

High-Risk Surgery Form

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