Consent to Perform Surgery

Client; ……………………………….………………………………. Phone; ……………………………….

Address; ……………………………….……………………………….
Horse; ………………………………. Breed; ………………… Age; ………… Gender; …………….
Colour; ……………. Microchip No; ………………………………. Brands; …………………………
Vaccination History (Please circle); Tetanus Y / N, Strangles Y/ N
Please list current diet; …………………………………………………………………………………………………………………………
Is the horse listed above currently being treated for any illness or injury other than the surgical procedure listed (please circle) Y/N. If yes please list the ailment/ injury and the current treatment; …………………………………………………………………………………………………………………………
Has the horse listed above been fasted at time of admission (please circle); Y/N,
If yes from time/ date; ………………..
Has the horse listed above ever had any procedures requiring anaesthesia previously (please circle); Y/ N
If yes please list any complications with either anaesthesia or surgery; …………………………………………….
The horse listed above is to have an anaesthetic and/ or surgical procedure. Every such procedure carries some risk and horses by nature pose some special risk. Whilst the vast majority of cases are uneventful and result in a satisfactory outcome, it is important to be aware of possible complications.
These include but are not limited to;
* Adverse anaesthetic reactions
* Limb fracture and injury during anaesthetic induction and recovery
* Post- operative infections, colitis, laminitis and colic
Some of these complications can result in death or require euthanasia, and the results of any surgery cannot be guaranteed. Nevertheless, it has been assessed that the benefits far outweigh the risks, and we are well equipped and skilled to minimise such risks. Pleases feel free to discuss any concerns you may have.
Please note if the horse is insured for mortality. It is an owners responsibility to inform the insurance company of the procedure the animal is to undergo.
I……………………………………..(owner/ agent) authorise the Gisborne Veterinary Clinic to administer anaesthesia and perform surgery on the horse listed above for;
(Procedure)……………………………………………………………………………………On (date)……………
I confirm that the insurance company …………………………………………………. Has been notified and the appropriate authority given.
I accept all surgical and anaesthetic risks including any complications that may develop as a result of the procedures, and acknowledge that these may incur additional fees.
I further agree to indemnify Gisborne Veterinary Clinic, its servants or agents, from any loss or liability which they may incur as a result of any inaccuracy whether intended or otherwise in this my declaration and acknowledge that the animal is kept on the premises at the owners risk.
I shall settle all charges incurred on discharge of my animal, including those associated with livery. I acknowledge that unless I have an established credit account I will pay the full balance of the account at the time of discharge.

Signed (owner/ agent); …………………………………………… Date;……………………..

Witness;…………………………………………