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Procedure Consent Form

AUTHORIZATION AND CONSENT FOR SURGERY AND RELATED TREATMENTS

Dr. Albert Charles Lynch – ACL Surgery LLC

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Our general practitioner veterinarian, or the surgeon who will perform the operation, will explain the operation or procedures to you before you decide whether or not to give consent.

YOU HAVE THE RIGHT NOT TO GIVE CONSENT.


If you have any questions, you are encouraged and expected to ask them. Your signature on this form indicates that:


(1) you have read and understood the information provided in this form.


(2) the operation or procedure set forth above has been adequately explained to you and you understand that you have the option to pursue consultation/intervention at a referral institute.


(3) your pet has had a thorough clinical exam within the last four weeks that confirms absence of comorbidities that would preclude general/local anesthesia and/or the planned surgical intervention.

(4) your primary veterinary clinician has advised pre-operative diagnostics within four weeks of the planned surgical intervention, which include specialty reviewed radiographs/ultrasound of your pet’s thorax, abdomen, pelvis and affected limb/region of presenting complaint.


(5) you have had a chance to ask questions.


(6) you have received all the information you desire about the operation or procedure.


(7) you authorize and consent to the performance of general and/or local regional anesthesia, including epidural and/or peripheral nerve blockade, off-label medications and advanced cardiopulmonary resuscitation efforts.


(8) you authorize and consent to the performance of the operation and procedure.


(9) you authorize and consent to the transfer to a referral setting in the event of complication that should require additional care, monitoring or intervention.


(10) your pet has been fasted for the last 12 hours and all recent medications (within the last month) and current medications are listed above, as well as any known medication allergies.

EVERY surgical operation or procedure, no matter how correctly the operation, procedure or related treatments are done, carries the risk of complications. Most risks and complications are known to the doctors, and can be explained in advance to you. Therefore, you can make an informed decision regarding whether or not you wish to consent to the operation. In addition, it is possible for complications to occur, with any operation, which have not been known to occur in the past, and cannot be explained or predicted by the health care professionals treating the patient. It is also possible for the same condition to occur, in the future, in other parts of the body.

Known complications for this procedure includes:


1. Morbidity or mortality as a result from general or local anesthesia including exacerbation of underlying organ dysfunction, abnormal blood clotting or emboli, neurologic abnormalities, cardiac dysfunction, aspiration pneumonia, persistent regurgitation/vomiting, airway/tracheal trauma.


2. Harmful or fatal reaction to medications – Some medication used may be off-licensed for use in veterinary species.


3. Change in diagnosis, or pre-operative mis-diagnosis, that necessitates an alternative treatment plan or surgical intervention.


4. Infection of the surgery site or surgical implant, with potential to spread infection to additional body cavities and organs.


5. Failure of normal tissue healing, disruption/opening of the surgical incision, accumulation of fluid at the site of surgery, suture reactions, exuberant scar formation or pigment changes at surgical site.


6. Abnormal, excessive or fatal bleeding.


7. Adhesion (abnormal sticking together) of tissues, including fibrosis of soft tissues and or musculature that may restrict joint motion.


8. Nerve trauma and or vascular damage from initial trauma and/or from surgical dissection or abnormal healing.

9. Non-union, delayed union or mal-union (failure of bone healing, healing of bone in delayed time frame, healing in malangulation) that may require additional surgical intervention, loosen or break implants, or exacerbate lameness/degenerative joint disease.


10. Limb shortening and/or mal-angulation of the limb.


11. Bone necrosis, resorption and or reduced bone density. Reduced bone density may occur beneath or adjacent to implants and lead to subsequent fracture and/or implant failure. Stress risers are especially common near metallic implants and/or osteotomies/fracture sites that can lead to subsequent fracture.


12. Loosening, breakage and/or migration of surgical implants, including operative tools, that may necessitate additional surgical intervention to attempt surgical explantation of the implant/tool. Metallic pins are especially prone to migration.


13. Intra-articular insult from implant that may exacerbate degenerative changes and/or require additional surgical
intervention.


14. Reaction or sensitivity to implanted surgical materials, including temperature related pain/lameness from implants.


15. Abnormal or extreme behavioral response to surgery and/or treatments, resulting in harm to the patient or others.


16. Failure of patient to submit to necessary post-operative confinement & restraint, or to tolerate splints/cast. Bandages
and/or splints/casts are especially prone to complications and associated wounds.


17. Development of abnormal growth due to growth plate damage at the time of initial trauma and/or as a result of surgical
intervention or implant position 11


18. Failure to resolve, or improve adequately, presenting complaint/clinical signs. This includes a failure to execute the planned surgical procedure (completely or partially), a recurrence of the clinical sign or similar syndrome, lameness or gait abnormalities associated with immediate or delayed damage to nearby peri-/intra-articular structures, progression and/or acceleration of degenerative joint disease.

I, THE UNDERSIGNED, understand that during the performance of procedures for the above situation(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedures, or other procedures different from those set forth previously. I hereby consent and authorize the performance of such procedures as necessary and desirable in the exercise of the veterinarian’s professional judgment. I have been informed and advised of the nature of these services and procedures, as well as the risks involved, and I also realize that results cannot be guaranteed, and that no guarantee regarding results has been given or implied. I understand that there is the possibility of complications, known and unknown, occurring as a result of this operation or procedure, which can occur even if all aspects of the treatment have been done correctly. I acknowledge that I have been advised of the known complications, and that complications can
increase the cost of the treatment. I agree to be responsible for these costs. I additionally authorize the use of appropriate anesthetics, pain medications, pathology examination of removed tissues, and the administration of other medications. I further agree to follow the veterinarians’ home care instructions. I agree to pay the fees for the operation, procedures and treatments, and I understand that the fee is not contingent upon the success of the procedure or the occurrence of complications. I understand that the estimated fees with which I have been provided are ONLY estimates, not a guarantee that the cost of the episode will be limited to that amount. I am the owner or authorized agent for the above-named animal, and I am over 18 years of age. I have brought this animal for the above-mentioned procedure(s) and have the authority to execute this consent and agreement.

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