Corneal Debridement AC Select Location*FremontPleasantonOwner Name*Owner Phone Number*Patient Name*Today's Date* MM slash DD slash YYYY Owner’s Date of Birth (needed for prescribing certain medications by the DEA):* MM slash DD slash YYYY Corneal Debridement with Temporary Tarsorrhaphy Suture* Right Eye Left Eye Both Eyes What time did your pet last eat?* : Hours Minutes AM PM AM/PM Approximately how much food does he/she eat?*Did you bring your pets medications here today?*Select OneYesNoIs your pet on any other medications besides eye medications?*Select OneYesNoIf so, please list the medication(s) and the dosage(s) below:Is your pet allergic to any medications?*Select OneYesNoIf so, please list the medication(s) below:Has your pet had any adverse reaction to a medication (oral, topical, injectable, etc)?*Select OneYesNoIf so, please list the medication(s) and the dosage(s) below:Has your pet ever had any adverse reaction to any procedures?*Select OneYesNoIf so, please list the procedure and what occurred below:Of the eye medications he/she is on, please indicate which medications you administered today and what time they were given.Is there anything else that you feel we should be aware of with regard to your pet’s health prior to surgery today?Has your pet ever had any seizures?*Select OneYesNoHas your pet ever had a past anesthetic event that you thought went poorly?*Select OneYesNoHas there been any history of neck, spine, or back disease in your pet? Any pain or discomfort in these areas?*Do you prefer eye ointments or drops?*Select OneEye OintmentsDropsDo you prefer liquid medications or pills?*Select OneLiquid MedicationsPillsIs your pet up to date with vaccinations?*Select OneYesNoDo you have any questions about the surgery today?*Select OneYesNoFor our Diabetic patients, please fill out the following:What is his/her regular insulin schedule? (Please indicate both the time you administer the insulin and the dose given each time.)How much insulin was given today and at what time? How much food was also given?Acknowledgement of RisksI understand the cost of the procedure is $2,023 - $2,236 which does not include the exam fee.*Please Sign or Initial I understand the risks of the procedure(s) include (but are not limited to) the following: 1. continued corneal ulcer 2. increased discomfort, which should be temporary 3. corneal abscess or infection 4. melting cornea 5. repeat procedure(s) may be necessary at additional costs 6. loss of eye*Please Sign or Initial Please Read and RespondI understand that because of unforeseen circumstances, the cost of rendered services may exceed the estimated cost. In this case, all charges are held as low as possible. The doctors and staff of Bay Area Animal Eye Care will be glad to go over itemization and explain any charges.*Please Sign or Initial I understand that it may be necessary, during the procedure or hospitalization, to provide emergency medical care in the event that I cannot be contacted. Therefore, I consent to and authorize the performance of such medical or surgical interventions as are necessary and desirable in the exercise of the veterinarian’s professional judgement.*Please Sign or Initial I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian.*Please Sign or Initial Procedural Risk AcknowledgementRisks of the procedure(s) include (but are not limited to) the following: 1. Anesthetic or sedation complications including death 2. Infection 3. Prolonged effects of anesthesia or sedationI have been advised as to the nature of the procedure(s) and the risks involved. I realize that results cannot be guaranteed.*Please Sign or Initial In the unlikely event of a cardiac or respiratory arrest during hospitalization or surgery, would you like the attending doctor to perform CPR to the best of our ability with the equipment available?*YesNoPayment AcknowledgementAn $800 surgery deposit will be due prior to drop off. Payment is due in full at pick up. Payment may be made in the form of cash, personal check, VISA, or MASTERCARD. A fee of $35.00 will be added to payable charges for returned checks.Please Enter Today's Date*I have read and understand this authorization and consent.*Please Sign or Initial
