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Service Agreement Form

SERVICES OFFERED TO YOU

  • ACL Surgery LLC (ACL) offers specialty surgical procedures (Services) to a hosting hospital, practice, or clinic, where the surgery is to be performed, including all employees (The Hospital).

  • ACL offers pre-operative and post-operative educational resources (Resources) to The Hospital.

  • The Hospital is invited to utilize ACL Services should The Hospital determine that the Services and Resources would be of value to The Hospital’s pet owner client (Pet Owner) and pet (The Patient).

  • A current ACL Services pricing guide will be provided to The Hospital, which is updated each year.

SUBCONTRACTOR STATUS

  • ACL operates only as subcontractors to The Hospital. ACL does not work directly for, nor does ACL offer credit to, the Pet Owner or The Patient except under special circumstances agreed upon in advance and in writing.

  • The Hospital is responsible for paying ACL Service fee. It is strongly recommended that the total ACL Service fee be collected by The Hospital from the Pet Owner as a required deposit, in advance of scheduling ACL Services.

  • The Hospital, and all employed staff members, are required to meet all the federal and state laws, as well as standards set by your State Veterinary Board, as it relates to, but is not limited to, business and personal licensure, business and personal insurance, controlled drug handling and logging, animal bailee coverage, maintenance of facility standards, and all other controlling requirements under all applicable laws.

CLIENT COMMUNICATION

  • The Hospital is responsible for clearly communicating with the Pet Owner that ACL is performing the Service on The Patient.

  • The Hospital is responsible for clearly communicating with the Pet Owner that The Hospital will be continuing The Patient’s post-operative care and communications.

  • The Hospital is responsible for clearly communicating with the Pet Owner what The Patient’s diagnosis is, available treatment management options, risks and complications, through The Hospitals complete understanding of the material present in Pet Owner Resources provided.

  • The Hospital is responsible for directing the Pet Owner to the Resources prior to scheduling ACL Services.

  • ACL is responsible for the immediate post-Service communication with the Pet Owner with reference to The Patient. This communication is to discuss Service findings and issue Service specific aftercare instructions.

  • The Hospital is responsible for all other Pet Owner communications, recheck visits and additional Patient care.

  • The Hospital is responsible for clearly communicating these aforementioned communication responsibilities regarding The Patient to the Pet Owner.

PRE-OPERATIVE APPROVAL VISIT (“Approval Exam”)

  • Prior to scheduling ACL Services, The Hospital is responsible for performing a complete history and physical examination with diagnostics (Approval Exam) on The Patient with the Pet Owner present.

  • The Hospital is responsible for interpreting the results of the Approval Exam, so as to ensure that The Patient has no abnormalities or comorbidities precluding the scheduling of ACL Services.

  • The Hospital is responsible for communicating the findings of the Approval Exam to the Pet Owner, including The Patient’s diagnosis that indicates that ACL Services are advised.

  • ACL Services may be scheduled for a period up to four weeks following completion of an Approval Exam on The Patient, after which time the Approval Exam must be repeated.

  • The essential components of the Approval Exam include, but is not limited to:

    • Complete physical exam with diagnosis and professional recommendation for surgical intervention in a clinically affected patient, normal cardiorespiratory auscultation, no abnormalities on rectal exam and freedom from dermatitis or other forms of infection

    • ECG trace should be observed by the attending veterinarian for 1-2 minutes. If there is concern for an abnormal ECG trace, then a veterinary cardiologist should be consulted

    • Radiographs should be performed and sent to a veterinary radiologist for review: Lateral thorax (3-view if there is any concerns), lateral abdomen (3-view if there are any concerns), lateral and VD pelvis, orthogonal views of the limb with the surgical diagnosis.

    • Minimal database: Hematology and chemistry blood panel, as well as urinalysis. If there are abnormal findings on this minimal database, then further investigation is required and may include a consultation with an internal medicine specialist and/or an abdominal ultrasound

  • Documentation of the Approval Exam is a requirement prior to scheduling ACL Services. Failure to comply with this requirement may result in The Hospitals scheduled ACL Service being cancelled and a fee being charged to The Hospital by ACL (50% of the scheduled Service fee).

  • Special circumstance – Fracture scheduling timeline:

    • 1) Low-energy trauma fractures: This may be scheduled as soon as the Approval Exam is completed by The Hospital (including same day if radiographs are sent for immediate radiologist review). Example patient with a low-energy fracture is a toy-breed dog that jumped out of their owner’s arms and presents with a radius and ulna fracture

    • 2) High-energy trauma fractures: This may be scheduled after the Patient has been monitored for 48-72 hours, in The Hospital or at a referral/emergency facility, due to the risk for intrathoracic and/or abdominal trauma that may not be immediately evident, such as urinary tract trauma. Example patient with a high-energy fracture being any patient with a hit by car type trauma, or any patient with multiple fragment (comminuted) fracture from unknown origin

SCHEDULING ACL SERVICES

  • Prior to scheduling ACL Services, The Hospital must complete the Approval Exam and collecting a financial deposit from the Pet Owner.

  • Prior to scheduling ACL Services, the Hospital is responsible for communicating to the Pet Owner that all financial estimates regarding The Patient and any potential ACL Services are provided by The Hospital, not by ACL.

  • Prior to scheduling ACL Services, The Hospital acknowledges that The Hospital is responsible for acquiring signed Pet Owner consent regarding The Patient and any planned ACL Services.

  • Prior to scheduling ACL Services, The Hospital must ensure that The Hospital will have appropriate facilities and supporting staff on the planned ACL Service date.

  • It is highly encouraged that The Hospital schedule two or three Services when planning an ACL Services date, and the ACL Service pricing guide reflects this.

SURGICAL CONSENT FORM

  • It is The Hospital’s responsibility to obtain a signed consent form from the Pet Owner, prior to the ACL Services being performed on The Patient. A consent form template is provided to The Hospital by ACL as a Resource.

  • ACL requires a surgical consent form to be completed and signed by both the Pet Owner client/authorized agent and The Hospital representative/agent before The Patient is admitted to The Hospital. Both the Pet Owner client/authorized agent and The Hospital representative/agent must be at least eighteen-years of age to sign this form.

  • The Hospital is responsible and liable for acquiring a signed consent form from the Pet Owner that confirms the ACL Services contracted by The Hospital on The Patient, site or limb for the scheduled ACL Services, that there are no guarantees of The Patient’s outcome post-Services, and that a multitude of complications are possible that The Patient and the Pet Owner could encounter.

  • In the event that the ACL Services advised and/or executed on The Patient are altered in any form by ACL or The Hospital, it is The Hospitals responsibility to acquire an updated signed consent form from the Pet Owner.

  • The Hospital is responsible and liable for educating the Pet Owner regarding this consent form, prior to the Pet Owner’s signing the consent form.

  • Failure of The Hospital to comply with this requirement may result in The Hospitals scheduled ACL Service being cancelled and a fee being charged to The Hospital by ACL (50% of the scheduled Service fee).

  • NOTE: This consent form also has a section for the pet owner to check off the planned surgical limb, as well as the hospital representative to check off the planned surgical limb after the owner has physically touched the limb they are planning for their pet’s (the patient) surgical procedure and indicated as such.

ACL ARRIVAL TIME TO THE HOSPITAL

  • There are a multitude of factors affecting ACL’s arrival time at The Hospital, including but not limited to traffic; therefore, ACL cannot promise a specific arrival time.

  • ACL will attempt to notify you if the arrival time is significantly late so The Hospital can be prepared for it and to explain this to the Pet Owner.

  • The Hospital must not promise any specific ACL arrival or Services time to the Pet Owner.

DIVISION OF RESPONSIBILITIES

  • ACL is responsible for confirmation of The Patient’s diagnosis, performance of the Services, immediate postoperative Pet Owner communication to relay surgical Services findings, issuing Service specific aftercare instructions, and assistance to The Hospital in the event of problem aftercare.

  • ACL is responsible for providing specialty implants and surgical drape packs for orthopedic procedures.

  • As an available Service to The Hospital, ACL is responsible for providing regional anesthesia techniques and associated local anesthetics when requested in advance at the time of ACL Service scheduling, subject to product availability

  • Surgical Nurse (employee of ACL): Frequently, but not on every operating day, ACL will have a Surgical Nurse to facilitate the conduct of ACL Services.

    • This Surgical Nurse is not there to relieve The Hospital’s employees from the responsibilities detailed below.

    • The presence or absence of the Surgical Nurse does not affect the responsibilities or staffing requirements of The Hospital during an ACL Services day.

  • The Hospital is responsible for The Patient’s diagnosis, assisting in development of a treatment plan, performing The Patient’s diagnostics, providing a clean surgical operating room of sufficient size without clutter, ensuring that The Patient is a safe candidate for anesthesia and surgery, performing The Patient’s anesthetic induction, maintaining and monitoring of The Patient under anesthesia, The Patient recovery and aftercare.

    • See previous section related to Communications and The Hospital’s responsibilities

    • See previous section related to Approval Exam and The Hospital’s responsibilities

    • See previous section related to Scheduling and The Hospital’s responsibilities

    • See previous section related to Consent and The Hospital’s responsibilities

  • The Hospital is responsible for providing adequate facilities and support staffing for ACL Services

    • A nurse from The Hospital is required to be dedicated specifically to each Patient undergoing Services requiring anesthesia and facilitation of that Patient’s Service. The Hospital is responsible for this dedicated staff member, for each Patient, overseeing and monitoring all aspects of The Patients care in The Hospital, including anesthetic monitoring and recording. This staff person will also be utilized as a circulating nurse to assist ACL.

    • The Hospital is responsible for providing all equipment, drugs, medications and prescriptions involved with ACL Services for The Patient.

    • The Hospital is responsible for preparing the operating room the night before scheduled ACL Services. This includes removing all unnecessary objects from the operating room and performing a thorough scrub-down with an antiseptic solution, including the overhead lights.

    • The Hospital is responsible for ensuring that The Patient is present in The Hospital before ACL arrival.

    • Fluids, catheters, induction agents and antibiotics are required to be laid out beforehand, by The Hospital. ACL requires that all patients be intubated, monitored and have an intravenous catheter, by The Hospital. The Hospital is required to provide drugs and Pet Owner consent for emergency resuscitation of The Patient.

    • The Hospital is responsible for ensuring that ACL Services are able to be performed by ACL on The Patient within one hour of ACL arrival to The Hospital.

    • The Hospital is responsible for providing an appropriate E-collar (“cone”) for The Patient after ACL Services have been completed. This E-collar must be rigid and of sufficient length that there is no question whether or not The Patient could get around it to get to the incision. If The Hospital is unsure, then The Hospital is to place a longer E-collar. The Hospital is responsible for putting this E-collar on The Patient once The Patient is extubated. The Hospital is responsible for securing the E-collar such that The Patient cannot remove the E-collar. The Hospital is responsible for all post-operative questions and concerns related to, or as a result of, the E-collar that you provided, or failed to provide, to The Patient. If the Pet Owner brings their own E-collar, it is The Hospital’s responsibility to ensure its adequacy, and to supply an appropriate E-collar if the one brought by the Pet Owner is inadequate for The Patient.

    • Failure of The Hospital to comply with these requirements may result in The Hospitals scheduled ACL Service being cancelled and a fee being charged to The Hospital by ACL (50% of the scheduled Service fee).

  • The Hospital is responsible for educating the Pet Owner what their responsibilities are.

    • For applicable elective orthopedic procedures, Pet Owners are required to study the Resources provided by related to The Patients scheduled Service. It is The Hospital’s responsibility that the Pet Owner is aware of these Resources, which may be online, prior to completion of the Approval Exam, so that the Pet Owner are knowledgeable and prepared to care for The Patient following Services being completed.

    • The Hospital is responsible for providing detailed discharge information to the Pet Owner, and ensuring that the Pet Owner understands the post-Service care The Patient requires.

    • Pet Owner non-compliance with post-Service care of The Patient is a major part of the development of complications. ACL will not be held responsible for Pet Owner client non-compliance.

ANESTHESIA AND ANALGESIA

  • The Hospital is responsible for The Patient’s anesthesia.

  • The Hospital is responsible for providing appropriate analgesia for The Patient’s ACL Service.

    • The Hospital is responsible for having adequate education in analgesic modalities available to patients prior to scheduling ACL Services. ACL Resources will be made available to The Hospital should this concern be raised by The Hospital to ACL in a timely manner, prior to scheduling Services.

    • It is strongly recommended for The Hospital to use a full mu opioid during The Patient pre-medication

    • It is strongly recommended for The Hospital to purchase Nocita for use in The Patients elective orthopedic procedures.

  • The Hospital is responsible for making sure The Patient is a safe anesthetic candidate, and for the induction, maintenance, monitoring and recovery from anesthesia.

    • See previous section related to Division of Responsibilities and The Hospital’s responsibilities

    • The Hospital is required to provide a dedicated trained employee to give full undivided attention to The Patient throughout the Service, recording all anesthetic monitoring parameters, and having sufficient staff to monitor The Patient’s recovery closely (particularly the first three-hours post-anesthesia).

  • As a Service, ACL is responsible for peripheral nerve blockade, when applicable.

  • Failure of The Hospital to provide these anesthesia and analgesia requirements may result in The Hospitals scheduled ACL Service being cancelled and a fee being charged to The Hospital by ACL (50% of the scheduled Service fee).

INFECTION CONTROL

  • ACL is responsible for aseptic technique during execution of Services.

  • The Hospital is responsible for providing a clean and clutter-free operating environment. Using the operating room for a storage facility is not satisfactory.

  • The Hospital is responsible for The Patient preparation, including the provision of heat support, clipping and scrubbing of the surgical site, notifying The Hospital attending veterinarian of any suspected dermatologic abnormalities, and positioning of The Patient on the table with a sterile surgical scrub being performed. All clipping of hair is required to be performed outside of the operating room by The Hospital staff.

  • The Hospital is required to perform two patient surgical site scrubs with chlorhexidine – The aim is to produce a hair-free, clean surgical site that is free from debris and has appropriate contact time (five minutes) with an acceptable patient pre-operative scrub:

    • The first scrub is performed in The Patient preparation area after clipping has been performed. This does not need to be a sterile scrub (i.e. does not require the use of sterile gauze and sterile gloves) and should aim for a contact time between the patient’s skin and chlorhexidine of approximately five-minutes

    • The second scrub is a sterile scrub performed with sterile surgical gloves and sterile (autoclaved) gauze. This is performed in the operating room and must be performed until no dirt or debris is present on the gauze after scrubbing

  • The Hospital is required give intra-venous antibiotics, such as cefazolin 22mg/kg, 30 minutes prior to surgery.

    • The first dose should be given during patient preparation, prior to moving through to the operating room

  • Subsequent doses must be administered every 90-minutes until skin closure is completed

  • Failure of The Hospital to comply with these requirements may result in The Hospitals scheduled ACL Service being cancelled and a fee being charged to The Hospital by ACL (50% of the scheduled Service fee).

AFTERCARE AND FOLLOW-UP

  • See previous section related to Division of Responsibilities and The Hospital’s responsibilities

    • The Hospital is responsible for all post-Service communications and follow-up visits with the Pet Owner and The Patient.

    • The Hospital is responsible for communicating, in phone or in person, with the Pet Owner every two weeks post-Service as a minimum. The Hospital is responsible for relaying these communications to ACL in a concise and timely manner.

  • ACL will act as an aftercare advisor only to The Hospital attending veterinarian, who is expected to give a detailed summary of The Patient and the concern to ACL.

    • ACL encourages the Pet Owner to upload photo, video and written updates regarding The Patient recovery from an ACL Service. This is ACL’s elected method of Service surveillance, and does not negate The Hospital’s requirement for Pet Owner communication every two weeks.

    • If ACL has a concern with The Patient’s progress from one of these photo, video or written updates sent from the Pet Owner to ACL, then ACL may communicate directly to the Pet Owner or ACL may forward the communication to The Hospital for The Hospital to address the concern, at ACL’s discretion.

  • In the event that The Patient has a post-Service complication, ACL may need to become directly involved with The Patient’s care. If this requires that The Patient schedule an appointment at The Hospital with ACL, then The Hospital is responsible for facilitating this and informing the Pet Owner of any Service fee for this appointment.

  • Failure of The Hospital to comply with these requirements may result in The Hospital being charged a consultation Service fee for each communication The Hospital has failed to provide the Pet Owner.

COMPLICATIONS AND REVISIONS

  • The Hospital is required to obtain a signed Pet Owner informed consent form so that there is unquestionable acknowledgement by the Pet Owner and The Hospital regarding the potential for an unsatisfactory Patient outcome post-Service, potential for complications related or unrelated to the Service and potential need for additional or revision Services.

  • ACL policy in the event of The Patient needing revision Services:

    • If ACL is certain that ACL has made a mistake: ACL will perform the revision Service at no charge to The Hospital.

    • If ACL is sure that there was Pet Owner client non-compliance or failure of The Hospital to provide their responsibilities detailed in this Service Agreement, then ACL will charge full Service fee for a revision.

    • If ACL is unsure of the origin of the complication that has resulted in The Patient’s requirement for revision Services, then ACL will offer the revision Service at reduced cost, at ACL’s discretion.

CONSULTATIONS

  • Any time ACL makes a trip to The Hospital to discuss The Patient, review radiographs, or examine The Patient, a consulting Service fee will be charged to The Hospital. Any time that ACL performs a phone consultation with a Pet Owner, a phone consultation Service fee will be charged to The Hospital.

    • ACL Service fee for consults with the Pet Owner present is higher than that for a consult without the Pet Owner client present.

    • Please note that there are no notes or write-ups provided by ACL to The Hospital for phone consultation Services.

    • If The Hospital would like a written case interpretation report for a Patient based on available diagnostics that The Hospital has provided ACL, then ACL can supply you this to The Hospital as a separate Service.

    • Arrival time cannot be guaranteed; therefore, consultations without the Pet Owner present are strongly advised. This is to avoid keeping Pet Owner’s waiting at The Hospital, and ACL arriving at The Hospital to find the Pet Owner angry about a protracted wait. This taints any efforts to concentrate on The Patient’s problems.

  • A standard consult Service interval is thirty minutes, and begins when I arrive at The Hospital. Additional consulting time intervals will be charged at the start of each thirty-minute interval. ACL driving time to The Hospital is billed at a 50% consultation Service rate each way. If the Pet Owner does not arrive within 30 minutes of ACL’s arrival, then ACL will depart and leave an invoice to The Hospital for the Services.

    • Consultations requiring anesthesia, palpation and special radiography can become quite time consuming and therefore quite costly, so prepare your Pet Owner in advance.

  • If ACL is already in The Hospital, ACL will do brief professional consults, examinations and radiograph reviews (with the Pet Owner not present) for The Hospital attending veterinarian at no cost. If ACL supplies The Hospital a written evaluation or review, then ACL will charge a Service fee (same fee as a phone consultation)

  • At ACL discretion, the pre-Service phone consultation Service fee will be discounted from The Patients subsequent surgical ACL Service. This effectively makes the pre-operative phone discussion with the Pet Owner a free Service, as it is discounted from the surgical Service fee.

PROCEDURE CANCELLATIONS

  • When The Hospital schedules an ACL Service, then that day, and available surgical procedure, is reserved for The Hospitals Pet Owner and The Patient.

    • Other Hospitals, Pet Owners and Patients requesting that ACL Service time are declined as a result of your (The Hospital) scheduled Service; therefore, short notice cancellations of scheduled ACL Services invoke a strict cancellation policy, as detailed below. Please ensure that all of your (The Hospitals) employees and the Pet Owner (for which the ACL Service is booked) understand this policy and timeline.

  • If the Pet Owner cancels, and The Hospital notifies ACL, with more than three full (>72 hours) working days (not including weekend days or holidays) before the scheduled Service, then there is no penalty.

    • As an example: If The Hospital scheduled an ACL Service for a Wednesday, then cancellation of that Service must be submitted before 09:00am the preceding Friday in order to avoid a cancellation fee.

  • If the Pet Owner cancels, or ACL is notified with less than three full (<72 hours) but greater than one full (>24 hours) working days (not including weekend days or holidays) before the scheduled Service, then ACL will charge The Hospital a $500.00 fee.

    • As an example: If The Hospital scheduled a Service for a Wednesday and The Hospital were to cancel that Service on Friday or Monday, then ACL will charge The Hospital a $500.00 cancellation fee

  • If the Pet Owner cancels, or ACL is notified with less than one full (<24 hours) working day (not including weekend days or holidays) before the scheduled Service, then ACL will charge The Hospital 50% of the Service fee.

    • As an example: If The Hospital scheduled a Service for a Wednesday and The Hospital were to cancel that Service on Tuesday, then ACL will charge The Hospital 50% of that Service fee as a cancellation fee

  • If the Pet Owner cancels the day of, fails to show up to their appointment or fails to adhere to the pre-operative guidelines regarding fasting, then ACL will charge The Hospital 50% of the Service fee.

    • The Patient must be dropped off to The Hospital in the morning for their planned elective Service so that the patient may be prepared for surgery. If the patient is not present when ACL arrives, then The Patient and Pet Owner forfeit surgery that day and ACL will charge The Hospital 50% of that Service fee as a cancellation fee.

  • If a Service is cancelled because anesthetic/surgical contraindications of The Patient are discovered on the day of the Service that could have been detected from an appropriately conducted Approval Exam, then ACL will charge The Hospital 50% of the Service fee

    • It is The Hospitals responsibility to be sure that The Patient has a correct diagnosis without contraindications on physical exam or in the pre-operative diagnostic tests. This is a big reason to do lab work several days in advance, not the morning of the operation.

PAYMENT OF ACCOUNTS

  • Following completion of the surgical procedure, ACL will send The Hospital an invoice for Services.

  • ACL offers a 30-day grace period on The Hospitals account and invoices. After that they are considered past-due and the ability to schedule additional ACL Services will be temporarily frozen and ACL will add 1.5%/month interest to The Hospital account balance.

  • ACL is not set up to accommodate The Hospitals payments by credit card.

  • ACL does not accept any form of payment from Pet Owner clients for surgical Servcies or fees that The Hospital is responsible for.

ACKNOWLEDGEMENT OF UNDERSTANDING

  • It is important to ACL that The Hospital and all staff members understand the terms of this Service Agreement.

  • Scheduling of ACL Services by The Hospital indicates acknowledgment and agreement to all terms detailed in this Service Agreement. If The Hospital does not agree to all terms of ACL’s offered Services, then it is The Hospitals responsibility to not use ACL Services.

  • The Hospital is encouraged to copy and file this document for your records.

I (authorized representative of The Hospital) understand and agree to all terms of service as outlined above:

Thanks for submitting!

ACL SURGERY LLC SERVICE PRICE GUIDE 2023

Procedures

  • Unilateral TPLO - $2,500

  • Bilateral TPLO - $4,000

  • Unilateral patellar luxation (no bone plate) - $1,900

  • Bilateral patellar luxation (no bone plate) - $3,250

  • Fracture (with bone plate) - $2,500

  • Fracture (no bone plate) - $1,900

  • Femoral head and neck excision (FHO) - $1,500

  • Ulnar osteotomy - $1,500

  • Other – Send case information and call Dr. Lynch for estimate

Additional Costs Per Surgery

  • Pre-operative phone call - $150

  • Peripheral nerve block (per patient) - $150

  • Nocita (Per site) - $175

  • Single surgery scheduled on a surgery day - $250

  • Add-on patellar luxation with TPLO that requires trochleoplasty - $350

  • Fracture/procedure that requires a second bone plate - $500

  • NOTE – Dr. Lynch will no longer be providing Help ‘em up harnesses

    • Please ensure that your pet owner orders this, or that your hospital begins carrying a supply

Consultations – The host hospital is responsible for booking ANY consultation for a pet owner with Dr. Lynch. All consultations are billed to the hospital.

  • Pre-operative phone call - $150

    • There is no write-up evaluation for this service

  • New patient phone consult - $150

    • For patients that are not scheduled for surgery and wish to review their pets case with Dr. Lynch

    • There is no write-up evaluation for this service – Attending veterinarian may contact Dr. Lynch to discuss details of this phone consultation with the pet owner

  • In-person consultation - $150 per 30 minutes (including write-up and travel time)

    • Drive time billed at 50% rate each way

  • Remote case interpretation - $100

    • Send case information and radiographs to Dr. Lynch and he will send you a formal written interpretation/report

    • Dr. Lynch does not contact the pet owner

Discounts – Discounts are offered to rescue organizations and hospital staff

  • Rescue organization discount 15%

  • Host hospital staff discount 25%

  • NOTE: These must be scheduled on a day with another procedure to get this discount

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