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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:

  1. You have read and understood the information provided in this form

  2. You have read and understood the information provided from Dr. Albert Lynch’s pre-surgical resources and website

  3. 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

  4. 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.

  5. 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

  6. You have had a chance to ask questions

  7. You have received all the information you desire about the operation or procedure

  8. 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

  9. You authorize and consent to the performance of the above indicated surgical operation and procedure

  10. You authorize and consent to the transfer to a referral setting in the event of complication that should require additional care, monitoring or intervention

  11. 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

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!

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