Surgical Consent | Dr. Albert Lynch

Complete Surgical Consent Form

Every surgical procedure and anesthetic episode will carry risk; therefore, Dr. Lynch’s surgical consent form has been included in your recovery booklet. You are expected to review this form, prior to consenting to it by admitting your pet to your primary veterinary facility the day of surgery. Basic lifesaving and resuscitative measures will be performed in the event of an emergency, unless you explicitly state otherwise to your veterinarian.

Your (authorized patient representative) signature on this form gives your consent and authorization to perform general anesthesia and the above stated surgical procedure on the above stated pet (patient).
Your 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. It is your responsibility to ensure that you feel confident and educated in your decision to pursue intervention on your pet (the patient), prior to signing this form.

YOU HAVE THE RIGHT NOT TO GIVE CONSENT AND NOT PURSUE INTERVENTION

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

You have read and understood the information provided in this form
You have read and understood the information provided from Dr. Albert Lynch’s pre-surgical resources and website
The operation or procedure indicated on this form has been adequately explained to you and you understand that you have the option to pursue consultation/intervention at a referral institute
Your pet has had a thorough clinical exam within the last four weeks from your primary veterinarian that confirms absence of comorbidities that would preclude general/local anesthesia and/or the planned surgical intervention.
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
You have had a chance to ask questions
You have received all the information you desire about the operation or procedure
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
You authorize and consent to the performance of the above indicated surgical operation and procedure
You authorize and consent to the transfer to a referral setting in the event of complication that should require additional care, monitoring or intervention
Your pet has been fasted for the last 12 hours and all recent medications (within the last month) and current medications are known by your primary veterinarian, 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:

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
Harmful or fatal reaction to medications – Some medication used may be off-licensed for use in veterinary species
Change in diagnosis, or pre-operative mis-diagnosis, that necessitates an alternative treatment plan or surgical intervention
Infection of the surgery site or surgical implant, with potential to spread infection to additional body cavities and organs
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
Abnormal, excessive or fatal bleeding
Adhesion (abnormal sticking together) of tissues, including fibrosis of soft tissues and or musculature that may restrict joint motion
Nerve trauma and or vascular damage from initial trauma and/or from procedural intervention, surgical dissection or abnormal healing
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
Limb shortening and/or mal-angulation of the limb
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
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.
Intra-articular insult from implant that may exacerbate degenerative changes and/or require additional surgical intervention
Reaction or sensitivity to implanted surgical materials, including temperature related pain/lameness from implants
Abnormal or extreme behavioral response to surgery and/or treatments, resulting in harm to the patient or others
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
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
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, development of additional surgical abnormalities, lameness or gait abnormalities associated with immediate or delayed damage to nearby peri-/intra-articular structures, progression and/or acceleration of degenerative joint disease

Dr. Albert Charles Lynch – ACL Surgery LLC

Pet (patient) owner (authorized representative) name:

Pet (patient) owner (authorized representative) email:

Pet (patient) name:

Patient planned surgical procedure:

Patient limb for planned surgical procedure:

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. I have physically pointed to the limb that I intend for my pet to have a surgical procedure performed on in the presence of a hospital representative. I am aware of the cancellation policy enforced upon scheduling a procedure with Dr. Albert Lynch. I have reviewed and studied all pre-surgical resources and recovery guidelines available from Dr. Albert Lynch

Signature of owner or authorized agent:

I, THE UNDERSIGNED, am an authorized representative of the hosting hospital for which the above patient’s procedure is scheduled. In addition to consenting and confirming all aspects of this consent form, I am also confirming that the host hospital and employees will conduct themselves with strict compliance of Dr. Albert Lynch’s (ACL Surgery LLC) service agreement.

Signature of hospital authorized agent:

I, THE UNDERSIGNED HOSPITAL REPRESENTATIVE/AGENT, confirm the identity of the patient presented and their intended surgical procedure as detailed above. I confirm this patient has been appropriately fasted and that the owner/authorized representative has physically indicated the limb that they are planning for their pet to have the mentioned surgical procedure performed on today. I confirm that the hospital has conformed to the requirements as detailed within the SERVICE AGREEMENT, including, but not limited to: • Pre-operative approval visit and diagnostics have been performed, with no abnormalities identified • Owner has been given access to SURGERY DAY EXPECTATIONS AND HOME RECOVERY PROGRAM booklet, prior to today • Hospital meets facility and staffing requirements, and is operating in accordance with the minimum requirements set forth within the ACL Surgery LLC service agreement

Signature of authorized hospital representative or agent:

Name of primary veterinarian that scheduled surgical procedure:

Confirm the limb that the owner points to when you ask them to physically touch the limb that they are intending for their pet have surgery on today:

Thanks for submitting!

< Previous

Back to Resources

Next >