Surgery Consent Form - Reed Mobile Veterinary Surgery

Client Name

First

Last

Pet Name

Client Email

Client Phone

It is OK for Dr. Reed's team to text the above phone number to get updates on my pet after they have returned home from surgery.

Yes
No

Is the person listed above the Emergency Contact for the day of surgery:

Yes
No

Emergency Contact For Day Of Surgery – Name (different from above)

Emergency Contact Phone

Family Veterinary Clinic Where Surgery To Be Performed

Surgery Date

Consent and Liability Waiver

I, the undersigned, confirm that I am the owner or authorized agent of the above-mentioned pet and have the authority to authorize medical treatment.
I understand that during the performance of the foregoing procedure(s), unforeseen conditions may arise that may necessitate an extension of the foregoing procedure or different procedures. I understand I will be updated of this as soon as possible and ideally before surgery, but sometimes this is not possible to foresee until the procedure is underway.
I also understand that it is impossible to guarantee the outcome of any medical procedure and that risks and the possibility of complications exist.
Any surgery has the risk of infection. I understand that treating a surgical site infection would require additional testing and costs.
I understand that the best recommendation to prevent by pet from licking their incision or chewing their stitches out is to use an Elizabeth collar (E-collar, cone collar). Other options exist (such as “pajamas”) and if I use an alternative I will ensure my pet cannot bother their incision or return to using the E-collar as recommended.

RMVS will occasionally use case reports from our patients for educational events for veterinarians and other veterinary professionals. This could include pictures of your pet's surgery, X-rays, lab results, and other parts of their medical record. The only identifying information used would be the name of your pet and maybe your first name only. This same information may sometimes be used for promotional on our website and/or social media.

I consent to the use of my pet’s information for educational events for veterinarians and other veterinary professionals, as well as RMVS promotional events.
I also consent to the use of any Thank You cards or emails I send to RMVS may be used for online testamonials and promotions.

If you are unsure what surgical procedure you pet is having with Reed Mobile Veterinary Surgery, please contact your family veterinarian to confirm the correct procedure is listed and details about the surgery are available. Alternatively, you may contact us at 414-678-1338 and we can help confirm the procedure planned for your pet.

Soft Tissue Surgical Procedures

Orthopedic Surgical Procedures

Anal Gland Removal: It has been recommended that your pet have an anal gland removed. This may be because of a mass in the anal gland, or because of chronic infections and/or impactions.

I understand that my pet must have restricted activity for 2 weeks while the incision heals. This means no running, jumping, or playing
I understand that my pet should be allowed to scoot as this can irritation the incision site while healing.
I understand that my pet may have some accidents and drop stool for the first week or so after surgery due to swelling and discomfort in the area. True, permanent fecal incontinence is very unlikely (though possible).
I also understand that if the mass biopsy comes back as malignant or aggressive, then the mass could recur in the same location, or spread somewhere else. I understand that the biopsy results may lead to a recommendation of further treatment for my pet, which could include more surgery or chemotherapy. If these recommendations are made, I understand that if I want to seek additional care for my pet, I should do so in a timely manner, before the cancer has a chance to spread.

Biopsy, Excisional: You pet has a mass that we will remove to send out for biopsy. We do not yet know for sure what this mass is, and that is why we are sending it out for biopsy to find out.

I understand that my pet must have restricted activity for 2 weeks while the incision heals. This means no running, jumping, or playing
I understand that if the mass biopsy comes back as benign and all of it was removed, it should be cured.
I also understand that if the mass biopsy comes back as malignant or aggressive, then the mass could recur in the same location, or spread somewhere else. I understand that the biopsy results may lead to a recommendation of further treatment for my pet, which could include more surgery, radiation therapy, traditional chemotherapy, or electrochemotherapy, etc. If these recommendations are made, I understand that if I want to seek additional care for my pet, I should do so in a timely manner, before the cancer has a chance to spread.

Biopsy of Mass: You pet has a mass and we are going to collect a sample of it to send out for biopsy. We do not yet know for sure what this mass is, and that is why we are sending it out for biopsy. We may use a large-bore needle (about the size of a pencil lead) to collect samples, or may make an incision in the skin and mass to take out a sample.

I understand that the skin over the mass will be shaved and that my pet may have stitches at the biopsy site, or possibly may not if only a small needle was used.
If there are stitches, I understand that my pet must have restricted activity for 2 weeks while the incision heals and until the stitches are removed. This means no running, jumping, or playing
I understand that the goal of this procedure is not to remove the mass, but to find out more information about it. Once the lab results are back (in about a week), Dr. Reed and/or my family veterinarian will review the results with me and discuss our next steps for my pet.

Bladder Mass Removal (Partial Cystectomy): You pet has a mass in the urinary bladder that we will remove to send out for biopsy. We do not yet know for sure what this mass is, and we get the biopsy results, we can determine what this means in the “bigger picture” for your pet and if any additional treatment recommendations may be made.

I understand that my pet must have restricted activity for 2 weeks while the incision heals. This means no running, jumping, or playing
I understand that it is normal to see blood in the urinate for 3-5 days (sometimes up to a week) after bladder surgery.
I understand that my pet’s bladder will be smaller after surgery and they will need more frequent bathroom trips for the first few weeks. Over time the bladder will stretch back out, but this can take a month or more.
I also understand that if the mass biopsy comes back as malignant or aggressive, then the mass could recur in the same location, or spread somewhere else. I understand that the biopsy results may lead to a recommendation of further treatment for my pet, which could include more surgery or chemotherapy. If these recommendations are made, I understand that if I want to seek additional care for my pet, I should do so in a timely manner, before the cancer has a chance to spread.

Corkscrew Tail Amputation (Caudectomy): Your dog has a tail that is shaped like a corkscrew and is causing pain by either growing back into the skin and/or due to infections in the skin folds. A very high amputation of the tail at the base (to remove the entire tail) has been recommended to remove this source of pain and/or infection.

I understand that my pet must have restricted activity for 2 weeks while the incision heals. This means no running, jumping, or playing
I understand that my pet may not be allowed to scoot their hind end or rub it against walls or furniture, as this can irritate the incision.
I understand that the entire tail will be amputated and my dog will not have even a stump remaining.

Tail Amputation (Partial): Your pet has a mass, infection, or trauma of the tail and the best recommendation is an amputation of part of the tail. We often leave about 1/3 of the tail, even if the issue is much further down the tail. We have to amputate so high because this is where we have enough soft tissues to close the tail over the central bone and have our best chance of success with healing.

I understand that my pet must have restricted activity for 2 weeks while the incision heals. This means no running, jumping, or playing. I will try to avoid getting my dog excited, which induces more wagging of the tail.
I understand that my pet may not be allowed to scoot their hind end or tail, or rub against walls or furniture, as this can irritate the incision while healing.
I understand that the best recommendation is that my dog wear the Elizabethan (cone) collar to prevent licking or chewing at the tail or incision site.

Neuter (Cryptorchid): Your pet has at least one testis that has not fully descended into the scrotum. This means the testis could be anywhere along its path of development. The testes begins inside the abdomen, behind the kidney, passes through the body wall in the groin, and then is supposed to enter the scrotum. Often the cryptorchid testis is under the skin in the groin, but sometimes it is still in the abdomen. The extent of surgery performed will depend on what your pet needs.

I understand that my pet must have restricted activity for 2 weeks while the incision heals. This means no running, jumping, or playing

Ovarian Remnant Removal: It is believed that your pet has remaining ovarian tissue after their previous spay surgery. This may be due to advanced imaging (ultrasound or CT scan) that shows potential tissue in the area of the ovary, or because your pet has been showing signs of heat and has had a blood test that showed elevated hormone levels consistent with remaining ovarian tissue. This surgery requires going into the abdomen and evaluating the area where both ovaries were previously located. Any abnormal tissue will be removed and submitted for biopsy to confirm if any ovarian tissue is seen, or if it is just scar tissue from the previous surgery.

I understand that my pet must have restricted activity for 2 weeks while the incision heals. This means no running, jumping, or playing

Parathyroid Gland/Mass Removal: You pet has bloodwork testing results consistent with primary hyperparathyroidism. This is primarily concerning the calcium level in the bloodstream being too high due to too much parathyroid hormone production from the abnormal parathyroid mass. Surgery is performed along the ventral (lower) side of the neck to evaluate and remove any abnormal parathyroid gland tissue. There are 4 parathyroid glands, and often only 1 needs to be removed, but sometimes 2 or 3 glands will be removed. As long as 1 gland remains, it should be able to do the work needed to maintain normal calcium levels, but it may be delayed in “waking up”. Please see our “Procedures” page for more.

I understand that my pet must have restricted activity for 2 weeks while the incision heals. This means no running, jumping, or playing
I know my pet must not be allowed to scratch or rub at the incision site. Since the incision is along the neck, a cone collar might rub along this area. A neck wrap, bandana, or scarf may be helpful. Or sometimes a cone collar can be tied to a harness to prevent the collar from rubbing along the incision site.
I understand that the most important risk of this surgery is postoperative hypocalcemia – if the blood calcium level gets too low before the remaining parathyroid glands “wake up” to start producing parathyroid hormone again. Signs to look out for include: scratching/pawing at the face (being itchy), stiff gait in the hind end, muscle tremors, and seizures. I will call my vet and/or local emergency center if these signs are seen.

Perineal Urethrostomy (PU): This is a procedure in male cats to create a larger urethral opening to prevent future life-threatening urethral obstruction for those suffering from FLUTD/FIC. This procedure requires amputation of the penis (and castration if the cat is not already neutered), and a wider segment of the urethra is sutured directly to the skin. The most concerning risk/complication from this procedure is stricture or narrowing of the opening, which could seal over with scar tissue and create an obstruction. The most important step to prevent stricture formation is using the Elizabethan (cone) collar so the cat cannot lick at the incision.

I understand that it is extremely important that my cat wears the Elizabethan (cone) collar at ALL TIMES after surgery for the first 2 weeks.
I understand that my pet must have restricted activity for 2 weeks while the incision heals. This means no running, jumping, or playing. It’s ideal to set up a medium-sized dog crate with a bed, litter pan, food, and water to be his “condo” for the next 2 weeks; otherwise a small room can work.
It is normal to have blood clots form at the surgery site and I understand it is recommended not to disturb these clots during the healing process.
I also understand this is not a cure of my cat’s underlying urinary issues and will continue regular rechecks with my family veterinarian to monitor my cat’s urinary health.

Prepucial Advancement: This is a procedure to bring the prepuce further forward to cover and protect the penis. This is typically done as a “nip, tuck” type procedure where we remove a crescent shaped section of skin from the belly in front of the prepuce, and then bring that skin forward when we close the incision, bringing the prepuce forward as well. This results in a semicircular or “C”-shaped incision on your dog’s belly. It is possible that additional procedures may be needed and this may not all be solved by one surgery alone. (copy)

I understand that my pet must have restricted activity for 2 weeks while the incision heals. This means no running, jumping, or playing
I understand that depending on how severely by dog is affected, and how much the skin may stretch out after surgery, additional procedures may be needed.

Prophylactic Gastropexy: This is a preventative procedure to suture the stomach to the right side of the body wall to prevent it from flipping on itself and developing Gastric Dilatation-Volvulus syndrome, which is a life-threatening surgical emergency. This procedure requires an incision into the abdomen (similar to a spay, but a larger incision).

I understand that my pet must have restricted activity for 2 weeks while the incision heals. This means no running, jumping, or playing
Since this is a surgery on the stomach, I understand that my pet should have smaller, more frequent meals for the first week after surgery. Soft food is also recommended.

Salivary Mucocele: You pet has a swelling under the chin and/or tongue that is due to saliva leaking out of the salivary gland/duct complex. We will have to shave the fur under the chin and the incision will be under the jaw. We have to remove the entire salivary gland/duct complex to remove the source of the leak.

I understand that my pet must have restricted activity for 2 weeks while the incision heals. This means no running, jumping, or playing
I understand that samples will be submitted for biopsy and bacterial culture to determine any other underlying issues. I will be informed of these results when they return in about a week.
I understand that it can take up to a month for the swelling to resolve after surgery. There is a very low risk of continued salivary leakage and if the swelling does not fully resolve, additional surgery may be recommended. I understand there would be additional costs for another surgery.

Total Ear Canal Ablation (TECA): It has been recommended that your pet’s entire ear canal be removed due to a mass or chronic infections and pain. The flap of the ear (the pinna) will still remain, but the entire ear canal and ear drum will be removed. For pets with an upright ear (cats, French Bulldogs, etc.), it is likely the pinna will stand upright anymore and won’t be symmetric to the other side. The facial nerve runs along the ear canal and inflammation of the nerve or damage at surgery can cause an inability to blink the eye on the same side of the face as the ear having surgery.

I understand that my pet must have restricted activity for 2 weeks while the incision heals. This means no running, jumping, or playing
I understand that my pet must not be allowed to rub their face as this can disrupt the incision. I understand that the Elizabethan (cone) collar is the best recommendation to prevent rubbing or pawing at the incision site.
I understand that samples will be submitted for biopsy and bacterial culture to determine any other underlying issues. I will be informed of these results when they return in about a week.
I understand that it is possible my pet will not be able to blink the eye on the same side of the face as the ear that is having surgery. This is often temporary and returns in a few weeks, but could be permanent. I understand that I will need to apply eye ointment in the affected eye until the ability to blink returns.

Superficial Digital Flexor Tendon (SDFT) Repair: Your pet has a luxation of the SDFT where it passes over the point of the ankle. The surgery to repair this might require drilling a hole in the calcaneus bone (the point of the ankle) and place sutures to anchor the tendon sheath back in place, or might require primary repair to suture to tendon sheath back together. Your pet will be in a splint for at least 4 weeks so they can’t move the ankle, which could damage the repair and cause the surgery to fail. It is important to monitor the bandage for slipping, get wet or soiled, or the toes becoming swollen. If these signs are seen, contact your family veterinarian as the bandage should be changed and the limb inspected.

My dog is having surgery on the LEFT hind leg today
My dog is having surgery on the RIGHT hind leg today
My dog is having surgery on BOTH hind legs today
I understand that my dog needs to be on “strict rest” for about 2 months (6-8 weeks) after surgery. This means no running jumping, or playing. Also no furniture or stairs. For these 6-8 weeks of recovery, my dog will be on a short, 6-foot leash when outside and only allowed outside for bathroom breaks. If my dog is too active, the suture could break down or stretch out, causing the surgery to fail. They are also more likely to develop bandage sores and other complications if being too active.
I understand that my dog will have a bandage/splint on the ankle for at least 4 weeks. This is to prevent the ankle from flexing, which can stress the repair and cause it to fail. After 4 weeks in a splint, a soft bandage will be placed for 1-2 weeks to allow the ankle to start to move again.
I will monitor the bandage as discussed in my discharge instructions and will notify my family veterinarian immediately if the bandage slips, becomes wet/soiled, or my dog’s toes are swollen.
I know the best recommendation is to use the Elizabethan collar (“cone collar”) while my dog has a bandage on the limb to prevent them from chewing at the bandage.

Extracapsular Stabilization (“ECS”) or Lateral Suture of the Knee: Your dog has a rupture of the cranial cruciate ligament (similar to the ACL in people). See the “Services” page for further explanation of this procedure, but I break it down as the round ball of the femur sitting on the angled slope of the top of the tibia, and now that the “parking break” of the cruciate ligament is torn, the ball wants to slide down the hill. With the ECS, we place a heavy gauge suture across the joint (from the femur to the tibia), though outside the joint capsule (hence “extra-capsular” in the name). This basically replaces the “parking break”. Scar tissue will also from along this suture, giving additional strength to the repair over time. This procedure is not recommended for larger dogs as the suture can break down or stretch out. This is also possible in smaller dogs, but it is a smaller risk.

My dog is having surgery on the LEFT hind leg today
My dog is having surgery on the RIGHT hind leg today
My dog is having surgery on BOTH hind legs today
I understand that my dog needs to be on “strict rest” for 2 months (8 weeks) after surgery. This means no running jumping, or playing. Also no furniture or stairs – I will carry my dog when needed. For these 2 months (8 weeks) of recovery, my dog will be on a short, 6-foot leash when outside and only allowed outside for bathroom breaks. If my dog is too active, the suture could break down or stretch out.
I know the best recommendation is to use the Elizabethan collar (“cone collar”) for the first 2 weeks until the incision is healed. I understand there is a small risk (< 3%) of infection getting to the permanent suture and the need for implant removal. There would be additional costs for any infection testing, treatment, or additional surgery.

Achilles’ Tendon Repair: Your pet has a partial or complete tear of the Achille’s tendon (common calcaneal tendon) at the bottom of the leg, just above the point of the ankle. The surgery to repair this tendon might require drilling holes in the calcaneus bone (the point of the ankle) to suture to tendon back to the bone, or might require primary repair to suture to tendon back together. Your pet will be in a splint for at least 6 weeks so they can’t move the ankle, which could damage the repair and cause the surgery to fail. It is important to monitor the bandage for slipping, get wet or soiled, or the toes becoming swollen. If these signs are seen, contact your family veterinarian as the bandage should be changed and the limb inspected.

My pet is having surgery on the LEFT hind leg today
My pet is having surgery on the RIGHT hind leg today
My pet is having surgery on BOTH hind legs today
I understand that my pet needs to be on “strict rest” for about 2 months (8 weeks) after surgery. This means no running jumping, or playing. Also no furniture or stairs. For these 8 weeks of recovery, my dog will be on a short, 6-foot leash when outside and only allowed outside for bathroom breaks. If my dog is too active, the suture could break down or stretch out, causing the surgery to fail. They are also more likely to develop bandage sores and other complications if being too active.
I understand that my pet will have a bandage/splint on the ankle for at least 6 weeks. This is to prevent the ankle from flexing, which can stress the repair and cause it to fail. After 6 weeks in a splint, a soft bandage will be placed for 1-2 weeks to allow the ankle to start to move again.
I will monitor the bandage as discussed in my discharge instructions and will notify my family veterinarian immediately if the bandage slips, becomes wet/soiled, or my dog’s toes are swollen.
I know the best recommendation is to use the Elizabethan collar (“cone collar”) while my pet has a bandage on the limb to prevent them from chewing at the bandage.

TPLO: Your dog has a rupture of the cranial cruciate ligament (similar to the ACL in people). See the “Services” page for further explanation of this procedure, but I break it down as the round ball of the femur sitting on the angled slope of the top of the tibia, and now that the “parking break” of the cruciate ligament is torn, the ball wants to slide down the hill. With the TPLO, we make a circular cut in the top of the tibia, so we can rotate that piece of bone to “flatten the hill”. We have to use a bone plate and screws to hold everything in place while the bone heals.

My dog is having surgery on the LEFT hind leg today
My dog is having surgery on the RIGHT hind leg today
My dog is having surgery on BOTH hind legs today
I understand that my dog needs to be on “strict rest” for 2 months (8 weeks) after surgery. This means no running jumping, or playing. I know the best recommendation is to use the Elizabethan collar (“cone collar”) for the first 2 weeks until the incision is healed.
For these 2 months (8 weeks) of recovery, my dog will be on a short, 6-foot leash when outside and only allowed outside for bathroom breaks.
A bone plate and screws will be placed in the bone to hold it together while it heals. X-rays will be needed at the 2-month recheck to confirm the bone has healed. I understand there is a small risk (< 3%) of infection getting to the implants and the need for them to be removed. Once the bone is healed this is OK because we don't need the plate/screws anymore, but I understand a procedure may be needed to remove the plate/screws. This will be discussed with me more if needed, in the future.

Patella Luxation Repair Surgery – MPL or LPL: Your pet's patella (kneecap) is dislocating or popping out of place. This can occur in either a medial (towards midline) or lateral (towards the outside of the knee) direction. The surgery to correct this could entail any of the following: deepen the groove at the bottom of the femur, adjust the soft tissues, and/or move the point of the shin bone into better alignment.

My pet is having surgery on the LEFT hind leg today
My pet is having surgery on the RIGHT hind leg today
My pet is having surgery on BOTH hind legs today
I understand that my pet needs to be on “strict rest” for 2 months (8 weeks) after surgery. This means no running jumping, or playing. I know the best recommendation is use the Elizabethan collar (“cone collar”) for the first 2 weeks until the incision is healed.
For these 2 months of recovery, my DOG will be on a short, 6-foot leash when outside and only allowed outside for bathroom breaks.
For these 2 months of recovery, my CAT will be confined to a small room or ideally a large dog crate as their “condo” during this time to prevent jumping or playing.
I understand this surgery has a high success rate, but it is reported that around 10% of patients can have the kneecap (patella) continue to dislocate after surgery. A large factor to prevent this recurrence is my ability to keep my pet restricted while the tissues are healing.
If the point of the shin needs to be moved, I understand that small pins will be placed in the bone to hold it together while it heals. X-rays will be needed at the 2-month recheck to confirm the bone has healed. I understand there is a small chance this pin could start to back out over time. Once the bone is healed this is OK because we don’t need the pin anymore, but I understand a small procedure may be needed to remove the pin.

TPLO & MPL: TPLO: Your dog has a rupture of the cranial cruciate ligament (similar to the ACL in people). See the “Services” page for further explanation of this procedure, but I break it down as the round ball of the femur sitting on the angled slope of the top of the tibia, and now that the “parking break” of the cruciate ligament is torn, the ball wants to slide down the hill. With the TPLO, we make a circular cut in the top of the tibia, so we can rotate that piece of bone to “flatten the hill”. We have to use a bone plate and screws to hold everything in place while the bone heals. Patella Luxation Repair Surgery – MPL: Your pet's patella (kneecap) is dislocating or popping out of place. This can occur in either a medial (towards midline) or lateral (towards the outside of the knee) direction. The surgery to correct this could entail any of the following: deepen the groove at the bottom of the femur, adjust the soft tissues, and/or move the point of the shin bone into better alignment. We can do both the TPLO and MPL repair at the same time.

My pet is having surgery on the LEFT hind leg today
My pet is having surgery on the RIGHT hind leg today
My pet is having surgery on BOTH hind legs today
I understand that my pet needs to be on “strict rest” for 2 months (8 weeks) after surgery. This means no running jumping, or playing. I know the best recommendation is use the Elizabethan collar (“cone collar”) for the first 2 weeks until the incision is healed.
For these 2 months of recovery, my dog will be on a short, 6-foot leash when outside and only allowed outside for bathroom breaks.
I understand the MPL correction surgery has a high success rate, but it is reported that around 10% of patients can have the kneecap (patella) continue to dislocate after surgery. A large factor to prevent this recurrence is my ability to keep my pet restricted while the tissues are healing.
A bone plate and screws will be placed in the bone to hold it together while it heals. X-rays will be needed at the 2-month recheck to confirm the bone has healed. I understand there is a small risk (< 3%) of infection getting to the implants and the need for them to be removed. Once the bone is healed this is OK because we don't need the plate/screws anymore, but I understand a procedure may be needed to remove the plate/screws. This will be discussed with me more if needed, in the future.

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