Surgical Release Form – Boerne Veterinary Clinic

Owner's Name *

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Phone I can be reached at today. *

Patient's Name *

Referring Hospital *

Referring Veterinarian *

Procedure Date *

IF YOU ARE UNSURE WHICH PROCEDURE YOUR PET IS HAVING WITH TSVS, PLEASE CHECK WITH YOUR REGULAR VETERINARY CLINIC TO ENSURE THE RIGHT CORRECT PROCEDURE IS LISTED AND DETAILS ABOUT THE SURGERY ARE AVAILABLE. ALTERNATIVELY YOU CAN CONTACT OUR OFFICE AT (800) 707-0167 AND WE CAN PROVIDE WHICH PROCEDURE YOUR DOG IS SCHEDULED TO HAVE WITH US AT YOUR VETERINARY CLINIC. *

I have read and understand.

Procedure *

Your pet is suspect of having a condition that affects one of its joints. This means that based on the physical examination and radiographs performed we suspect a soft tissue or bone structure localized inside the joint to be affected/damaged. The structure(s) likely to be affected depend on the joint in question, the nature of the trauma (if any occurred), the age and the breed of the animal. A diagnostic arthroscopy was recommended to confirm the diagnosis and better recommend treatment. In this procedure, one to three small incisions are made through the skin and joint capsule to allow for placement of a small diameter camera. The camera will allow inspection of the internal structures of the joint and facilitate diagnosis. Small instruments may also be introduced to facilitate exploration and/or treatment of the affected structures if possible. Some structures may be visualized and may not be accessed through the small skin incision and small instruments, and others may not be fully visualized by the camera. Once a diagnosis is made, a treatment will be recommended. Surgical treatment of the affected structure(s) may be done in a minimally invasive manner (using arthroscopic instruments and camera) or via an arthrotomy (larger incision made through skin and joint capsule). Below are listed some of the common intra-articular injuries that can be diagnosed and sometimes treated by arthroscopy: Osteochondrosis Dissecans (OCD): In this condition, a portion of the articular cartilage becomes detached from the underlying bone and may become free in the joint causing persistent inflammation, pain and eventually arthritis. This is more often found in young dogs. The recommendation is to surgically remove the diseased cartilage fragment. Depending on the location and size of the fragment this can be done in a minimally invasive manner using the scope (camera) to assist. Cranial cruciate ligament tear: This is one of the most common injuries that affects the hind legs of dogs. The tear can be diagnosed and sometimes debrided by arthroscopy, but the ligament can’t be repaired directly. The recommended treatment involves a more advanced procedure called a tibial plateau leveling osteotomy (TPLO), modified or neutral wedge cranial closing ostectomy (mCCWO), or an extracapsular repair to help stabilize the joint depending on the size of the patient and the tibial plateau angle. Caudal cruciate ligament tear: This ligament is affected a lot less often than the cranial cruciate ligament and it may tear as an isolated incident rarely. The tear can be diagnosed and sometimes debrided by arthroscopy, but the ligament can’t be repaired directly. Often rehabilitation therapy can overcome this injury or in rare instances it may need to be stabilized. Meniscal tear: This can occur as a single problem, but it is most often associated with cranial cruciate ligament tears. The meniscal injury can happen at the same time that the cruciate ligament tear or after the tear has been addressed by a TPLO or Extracapsular repair procedure. Treatment involved removing the affected part of the meniscus. In rare instances particularly in Boxer breeds, we can have an isolated lateral meniscal tear that needs to be addressed. It is uncertain why this injury occurs primarily in Boxer breeds. *

I have read, understand, and consent.

Your pet has been diagnosed with a luxated hip that needs surgical repair. You have elected to have a procedure called a toggle repair method where we place an artificial ligament in the hip and suture the torn joint capsule after reducing the dislocated hip. The goal of any orthopedic surgery is fast return to function. If, during surgery, it is discovered that the cartilage is damaged, we may need to do an FHO. Unfortunately, in some cases, complications can arise, especially in our animal patients where bed rest and crutches are never an option, and the artificial ligament can fail. With proper home care though the surgery is 70-90% successful. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

My pet is having surgery today on the: *

Right Leg
Left Leg
Both Legs

Your pet has been diagnosed with a rupture of the Achilles tendon. This is a devastating injury that if left unrepaired will result in a severe lameness making use of limb impossible. Tears can occur in the gastrocnemius muscle, the tendon itself, or it can avulse from the attachment on the bone. Medical management with casts, splints or bandages alone is usually unsatisfactory. Tendons heal very slowly, more slowly than broken bones. Six weeks after repair, tendons have 56% of their normal tensile strength and by 1 year have 79% of normal strength. Dogs only strain their tendons to only 25% to 33% of their maximal capability so the strength obtained by 6 weeks after tenorrhaphy (tendon repair) is generally adequate to withstand limited exercise and the strength obtained at 1 year is adequate for unlimited exercise based on studies and clinical impressions. Studies indicate tension across the wound should start 3 weeks after tenorrhaphy but activity needs to be with limited loads and carefully supervised slow walking. To accomplish this, it is best to support the repair with a trans-articular external fixator (pins through the bones across the tarsal joint connected on the outside with titanium rods and adjustable hinges). This allows your pet to walk on the leg without bulky and dangerous casts and splints. We can also adjust the angle of the fixator at 3 weeks to put a slight amount of strain across the tendon and slowly adjust the fixator post-operatively to control how much strain the tendon is subjected to over time. Fixators require daily cleaning and care in order to function properly. In most patients, the fixator is removed by 6-8 weeks and replaced with a light support bandage. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with anal gland problems that necessitate surgical removal or marsupialization (creating an open pouch). This can include abscesses, recurrent infections, impactions, or general discomfort. Often both glands are removed at the same time even if only one gland has been having problems to prevent future problems on the other side. Although every effort is made to prevent or minimize complications, any surgery near the rectum has a higher complication rate than other areas of the body. Besides the obvious issue of fecal contamination that can lead to infection, pets frequently lick or scoot after surgery which can irritate the incision or prematurely tear out any sutures if they are utilized. Additionally, bowel movements can be affected due to post-operative discomfort and many times your veterinarian may prescribe stool softeners for a short time until the surgical wound is healed. Previous surgery or infections can make removing the entire gland more difficult and increase the chance of draining tracts forming after surgery. The goal of surgery is to remove the entire sac and lining as well as the duct to prevent future problems. If any part of the gland is inadvertently left behind, it can secrete anal sac fluid under the skin which can lead to infection and more surgery. Marsupialization of the anal sac, involves creating a an open pouch from the closed pouch, which allows the anal sac to dry out and cease to produce fluid. *

I have read, understand, and consent.

Procedure: *

Unilateral
Bilateral

Procedure: *

Anal Gland Excision
Marsupialization

Anal tumors are not uncommon in dogs and cats. These can be tumors that grow in or around the rectum, or more commonly, a tumor that grows from the anal gland. These tumors can be benign or malignant. A pre-surgical needle aspirate or biopsy is highly recommended so the surgeon can know how aggressive to be at the time of removal. Malignant tumors need a wider margin of excision than benign tumors and have a higher chance for recurrence or spread to other parts of the body. Unfortunately, sometimes it is impossible to get a definitive diagnosis without removing the entire tumor. Even with aggressive surgery, these tumors occasionally re-grow and need further surgery. Rarely, the tumor can be so invasive that complete excision is not possible without damaging the rectum or the nerves that control defecation. Neutered pets have less anal tumors than un-neutered pets and neutering at the time of surgery is critical to diminish the chance of recurrence. We also highly recommend removing both anal glands at the time of surgery to prevent further tumor growth in the other gland. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Procedure: *

Perianal/Anal Gland Tumor Excision
Neuter (Castration)
Epidural
Bilateral Anal Gland Removal if Anal Gland Tumor

Your pet has been diagnosed with a ruptured ligament and/or fractures of the bones involving he carpus or tarsu that needs surgical repair. Orthopedic surgery is a combination of both art and science and the orthopedic surgeon will evaluate your pet’s radiographs and determine the best method of repair given your pet’s age, extent of injury, underlying arthritis, and the home environment for post-surgical rehabilitation. Joint fusion (arthrodesis) is a surgery in which all the cartilage is meticulously removed from the joint surfaces in order to get the bones to fuse together forming one large bone and eliminating the moving joint. This procedure is done whenever the joint is injured beyond repair to prevent chronic pain and discomfort. Your surgeon may fuse part of the joint (partial arthrodesis) or the entire joint (panarthrodesis) depending upon the extent of the injury. In most cases, a specialized bone plate, external fixator, or pins and wires are used to stabilize the joint after surgery. In order to prevent implant failure with plates or pins and wires, an external splint or cast is needed to support the joint. Early healing is usually visible within six to eight weeks and many times the splint or cast can be removed shortly thereafter. External fixators have the advantage of not needing a cast or splint but do require daily cleaning and weekly bandage changes at home. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Procedure: *

Carpal or Tarsal Partial
Panarthrodesis
Epidural pain injection if rear leg surgery

Your pet has been diagnosed with laryngeal paralysis. The goal of surgery is not to completely eliminate all the noise that is present pre-operatively, but to reduce it to a level that allows your pet to breathe easier. Please be aware that although your pet should be improved after surgery, their breathing will never be completely normal. As many as 20% of patients with laryngeal paralysis have an underlying illness that may not be apparent at the time of surgery including neurologic disease, low thyroid function, myasthenia gravis, or simply a genetic predisposition to the disease as seen in older Labrador Retrievers. Any patient with a compromised airway should avoid stress whenever possible. Also, activity should be limited to moderate levels and on hot days they should be kept in a cool environment. Lastly, an ideal body weight should always be maintained. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Procedure: *

Arytenoid lateralization
Soft Palate Resection and Everted Laryngeal Saccules Resection (if present)

Your pet has been diagnosed with bone lesion that requires a biopsy and will be undergoing surgery to determine the cause of this lesion. The surgeon will carefully examine the entire the region for any abnormalities and take a biopsy of the affected region during the procedure. It is important to identify the cause of the lesion to further direct your pet’s treatment recommendations. There a some instances when biopsy of the affected region does not yield an answer due sample representation. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with brachiocephalic airway syndrome. The major components of this syndrome include stenotic nares (nostril openings too small), an overlong soft palate which interferes with normal breathing resulting in noisy respirations, and everted laryngeal saccules (eversion or prolapse of the mucosal lining of the laryngeal crypts) which also interfere with normal respirations. Surgery is designed to correct these abnormalities thereby making it easier to breath and reducing the noise associated with the syndrome. The goal of surgery is not to completely eliminate all the noise that is present pre-operatively, but to reduce it to a level that allows your pet to breathe easier and stop the progression of the syndrome. Without surgery, further collapse of the larynx can occur which can result in complete obstruction of the airway and collapse of your pet with strenuous exercise. Please be aware that although your pet should be improved after surgery, their breathing will never be completely normal. Any patient with a compromised airway should avoid stress whenever possible. Also, activity should be limited to moderate levels and on hot days they should be kept in a cool environment. Lastly, an ideal body weight should always be maintained. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Procedure: *

Soft palate resection
Stenotic nares resection (if needed)
Everted laryngeal saccules transection (if present)

Your pet has been diagnosed with a “Cherry eye” or protrusion of the third eyelid gland caused by enlargement of the gland that requires surgical correction. There is currently numerous theories behind of the origin of this disease. Most patients are affected at a young age (usually one year or less). The problem can occur in one or both eyes. Common canine breeds affected include American and English Cocker spaniels, English bulldogs, beagles, Pekingnese, Boston terriers, Basset hounds, Shih Tzus, and Lhasa apsos. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with a congenital cleft palate or defect in the upper rough of their mouth and soft palate. You have elected to have a procedure which attempts to close these defects located within the oral cavity. The goal during any surgery is return your pet to normal health. Most of these patients diagnosed with cleft palates have some form of aspiration pneumonia present. Unfortunately, in some cases, complications can arise, especially in our animal patients where they are young, small, immature and already have aspiration pneumonia. Your pet may require a feeding tube postoperatively to allow the tissues to heal. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with bladder stones (uroliths) that require surgical removal. There are several different types of bladder stones that can develop within the bladder or urinary tract of the dog/cat and complete surgical removal depends upon the size and location. Occasionally, these bladder stones can become lodged in different parts of the urinary tract (urethra and/or ureter) necessitating emergency surgery or treatment. Additionally, these bladder stones can cause chronic urinary tract infections if they are not removed. Certain types of breeds of dogs are predisposed to develop select types of bladder stones. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Procedure: *

Epidural
Cystotomy (opening up the bladder) and urolith (bladder stone) removal
Culture and sensitivity

Your pet has been diagnosed with a diaphragmatic hernia. In most cases, these are the result of some sort of trauma. Sometimes, like in Weimariners, the hernia is a congenital defect that was present since birth. Rarely, the hernia is present within the pericardial sac surrounding the heart. Since the large thin muscle that makes up the diaphragm is not visible on plain radiographs (if they were taken at the time) you cannot diagnose the underlying injury until organs from the abdomen inadvertently work their way into the chest cavity and interfere with respirations. Acute hernias tend to be less complicated than the others as there is little time for adhesions to form between the organs and the lungs. In chronic cases, the organs not only adhere (stick) to the lungs in some cases, but the original tear tries to heal and sometimes we have to enlarge the hole in the diaphragm in order to be able to safely return the organs to the abdomen. Additionally, it is not uncommon for there to be inadvertent damage to the lungs that could require additional treatment at additional cost. Sometimes the lungs can be repaired with small sutures or glue, and sometimes the damage is so severe that the lung has to be removed. This requires extending the abdominal incision into the chest by cutting across the sternum. There are some patients where the hernia is a congenital defect from birth. These present additional unique challenges to chronic hernias. Sometimes there is a portion of the diaphragm missing and we need to utilize expensive marlex mesh to build a new diagphragm. Since many times the stomach, spleen, pancreas, liver, and intestines are all in the chest cavity, the abdominal wall shrinks down making it sometimes impossible to return all the organs and safely close the incision. In these cases we occasionally have to wait for the muscle to stretch enough to allow complete closure at a second surgery. Although things are very taught, we usually are able to get things back where they belong and close the incision in one surgery. Chest tubes are placed after surgery in chronic cases and must be cared for in the hospital and have 24 hour supervision. If your pet chews on a chest tube or uses a back leg to pull it partially out without anyone to intervene, life threatening pneumothorax can occur. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Procedure: *

Diaphragmatic Hernia Repair
Possible Thoracotomy and Lung Lobectomy
Damaged Lung Repair

Your pet needs to have a digit amputated from the forelimb or hindlimb due to irreparable damage, severe fracture injury, tumor, or chronic infection. The primary weight-bearing digits are the third and fourth digits. Typically the level of amputation in the digit is determined by the site affected and location within the limb. Radiosurgical equipment is utilized to diminish bleeding and swelling and pain and anesthesia is utilized to insure comfort upon awakening from the surgery. Bandages are sometimes used in digit amputations. Your pet will very quickly adapt to their new center of gravity and ambulate very well. Most patients adapt within a week, although some require some coaxing and physical therapy and can take up to four weeks to walk well without support. Lameness typically results if more than two digits or the third or fourth digit is removed. Low-grade persistent lameness (pain or uncomfort) after amputation of the third or fourth digit may occur. Digit amputation performed due to tumor or mass removal does not guarantee complete removal of the cause. Often times, spread of the original cause has occurred and should be further investigated by evaluating other areas of the body and the closest lymph nodes for detection of cancer cells. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet requires an esophagostomy (feeding) tube placement due to medical reasons to provide nutrition. This will require a minor surgical procedure under anesthesia. As with any surgical procedure, complications may arise including, surgical site infection, removal of the tube by your pet, inability to maintain patentcy of the feeding tube. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been recommended to receive an exploratory surgery to identify abnormal contents within the abdomen (intestinal foreign body, mass or tumor, abscess, puncture wound, etc). The objective of surgery is identify any abnormal areas or sections of organs and remove them. Often times, more than one area is affected, however one specific organ or section of an organ can be affected only. The goal during surgery is to identify the abnormal contents within the abdomen and remove all or most of the abnormal contents or section of intestine that might be affected. This may require numerous incisions within the intestine or organ or removing a section of intestine or entire organ. Other organs within the abdomen can be affected and may need to be removed as well like Gastrointestinal tract, Urinary tract, Liver, Spleen, Pancreas. Many different surgical techniques are available to the surgeon but using a variety of suture or electrosurgical techniques (Ligasure), the abnormal section will be removed or debulked as necessary. Other intestinal organ biopsies may be warranted. Although every effort is made to prevent or minimize complications, any surgery near these important structures are not without complications. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with an abdominal hernia (inguinal, scrotal, femoral, or umbilical) hernia that requires surgical repair. Hernias result from weakening of the abdominal musculature or normal opening where organs pass through. This can be congenital or traumatically induced. · Umbilical hernias occur through the umbilical ring · Inguinal hernias are protrusions of organs or tissue through the inguinal canal adjacent to the vaginal process · Scrotal hernias occur when defects in inguinal ring allow abdominal contents to protrude into the vaginal process through the ring · Femoral hernias occur through a defect in femoral canal The objectives of the surgery are to replace the contents of the hernial sac into the abdomen and reconstruct the holding layer to the ring or defect in abdominal musculature. Many different surgical techniques are available to the surgeon but using a variety of suture techniques is done most common to remove the hernia sac or repair the defect in the abdominal wall. On occasion, if your pet has very weak or insufficient muscles, a synthetic Marlex mesh is used to rebuild or reinforce the area. If your pet is not neutered, neutering is necessary to allow proper healing and prevent recurrence. There is some belief that sex hormones can contribute to the formation of the defects. Although every effort is made to prevent or minimize complications, any surgery near these important structures are not without complications. Besides the obvious issue of repair failure due to obesity or straining from pain, pets frequently lick or chew the sutures after surgery which can irritate the incision or prematurely tear out any sutures. Additionally, bowel movements can be affected due to post-operative discomfort and many times your veterinarian may prescribe stool softeners for a short time until the surgical wound is healed. The biggest complication of hernia repair is recurrence or dehiscence. It is critical that your pet should have an e-collar placed postoperatively to avoid issues with suture. Additionally, strict confined, controlled activity (leash activity only) is imperative for several weeks till defect has healed from surgery. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with a ruptured ligament that needs surgical repair. Orthopedic surgery is a combination of both art and science and the orthopedic surgeon will evaluate your pet’s radiographs and determine the best method of repair given your pet’s age, extent of injury, underlying arthritis, and the home environment for post-surgical rehabilitation. The surgeon may utilize one or more methods of repair depending upon the extent of damage seen inside the joint. This can include other torn or stretched ligaments, osteophytes growing along the joint, and meniscal damage (cartilage). The goal of any orthopedic surgery is fast return to function of the injured joint. In most cases, there will be no complications and your pet’s joint will heal fully in 8-12 weeks, although with this severe injury the joint will never be good as new. Unfortunately, in some cases, complications can arise, especially in our animal patients where bed rest and crutches are never an option. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with a ruptured ligament that needs surgical repair. Orthopedic surgery is a combination of both art and science and the orthopedic surgeon will evaluate your pet’s radiographs and determine the best method of repair given your pet’s age, extent of injury, underlying arthritis, and the home environment for post-surgical rehabilitation. The surgeon may utilize one or more methods of repair depending upon the extent of damage seen inside the joint. This can include other torn or stretched ligaments, osteophytes growing along the joint, and meniscal damage (cartilage). The goal of any orthopedic surgery is fast return to function of the injured joint. In most cases, there will be no complications and your pet’s joint will heal fully in 8-12 weeks, although with this severe injury the joint will never be good as new. Unfortunately, in some cases, complications can arise, especially in our animal patients where bed rest and crutches are never an option. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with a hip problem that cannot be repaired. You have elected to have a salvage procedure called a femoral head and neck ostectomy where we excise the ball portion of the hip joint and allow a “false joint” of scar tissue to form and relieve your pet’s hip pain. The goal of any orthopedic surgery is fast return to function. Unfortunately, in some cases, complications can arise, especially in our animal patients where bed rest and crutches are never an option. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with a fractured bone that needs surgical repair. Orthopedic surgery is a combination of both art and science and the orthopedic surgeon will evaluate your pet’s radiographs and determine the best method of repair given your pet’s age, type of fracture or fractures, and the home environment for post-surgical rehabilitation. The surgeon may utilize one or a combination of pins, wires, screws, bone plates, or external fixator repair. The goal of any orthopedic surgery is fast return to function of the broken bone. Many times the method of repair can only be properly determined during surgery as fissures (small cracks in the bone) sometimes do not show up on a radiograph and can preclude certain types of fixation which would split the bone and worsen the fracture. Other times, in open or compound fractures or gunshot wounds that are contaminated, plates and screws can not be used as any infection would be difficult to correct. In most cases, there will be no complications and your pet’s bone will heal fully in 8-12 weeks. Unfortunately, in some cases, complications can arise, especially in our animal patients where bed rest and crutches are never an option. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Gall bladder disease is a common problem in dogs. Most of the time, the gall bladder is filled with sludge or stones that block the flow of bile necessary for the proper digestion of our food. In most cases, simply removing the gall bladder is all that is needed to resolve the problem. Before we can remove the gall bladder, a small incision must be made in the small bowel to find the bile duct opening and check for patency with a small catheter. Occasionally, the problem can be more severe and involve a ruptured bile duct with leakage of bile, tumors obstructing the duct, or infection that leaks into the liver tissue causing jaundice (yellow skin staining). Sometimes we need to reroute the bile flow from the gall bladder directly into the small intestine bypassing the obstruction. These patients with liver dysfunction are at slightly greater risk to undergo anesthesia but without surgery the condition can become fatal. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with a fractured jaw that needs surgical repair. Orthopedic surgery is a combination of both art and science and the orthopedic surgeon will evaluate your pet’s radiographs and determine the best method of repair given your pet’s age and the type of fracture or fractures. The surgeon may utilize one or a combination of pins, wires, screws, bone plates, or external fixator repair. The goal of any orthopedic surgery is fast return to function of the jaw. Many times the method of repair can only be properly determined during surgery as fissures (small cracks in the bone) and temporomandibular joint fractures sometimes do not show up well on a radiographs unless special views (open mouth) are taken under anesthesia. Often, due to the large number of small bones and overlying skull bones, radiographs will need to be examined by a veterinary radiology specialist necessitating two anesthetics, one for the radiographs and one for the surgery. Other times, in open fractures, bite wounds, or gunshot wounds that are contaminated, plates and screws can not be used as any infection would be difficult to correct. In addition, some cases will require post-operative wiring of the jaw with liquid feeding to protect the implants. If teeth are involved in the fracture, they may need to be removed now or at a future time to prevent abscessation. In most cases, there will be no complications and your pet’s bone will heal fully in 8-12 weeks. Unfortunately, in some cases, complications can arise. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet needs to have his/her leg amputated due to irreparable damage, severe fracture injury, tumor, or muscle, tendon or nerve damage. Front legs are amputated with the scapula bone to prevent unsightly sticking out of the scapular spine after muscle atrophy. Rear legs are usually amputated by cutting the femur bone near the joint instead of disarticulating the hip as it is less painful, less expensive, and more cosmetic. If your pet has disease near the hip joint or a tumor in the femur bone then disarticulation is necessary to fully treat the problem. Radiosurgical equipment is utilized to diminish bleeding and swelling and pain and epidural anesthesia is utilized for rear leg amputation to insure comfort upon awakening from the surgery. Bandages are sometimes used in front leg amputations but rarely in rear leg surgeries. Your pet will very quickly adapt to their new center of gravity and ambulate very well. Most patients adapt within a week, although some require some coaxing and physical therapy and can take up to four weeks to walk well without support. Three legged patients can run, jump and play with little handicap. Since humans are bipeds, losing a limb leaves them with one leg which is a severe handicap. Our pets walk on four legs and losing one leg to become a triped is not nearly as debilitating. Patients can even do quite well with just two legs, even if they are on the same side! Lastly, pets do not have any emotional component to their loss of a limb and do not “feel sorry for themselves” or have any signs of depression after undergoing loss of a limb. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

My pet is having surgery today on the: *

Front Leg
Rear Leg
Left Leg
Right Leg

Procedure: *

IM Pin removal
Nylon suture removal
Osteophyte removal

Your pet has been diagnosed with a liver mass (tumor or growth) that needs to be excised and biopsied. Depending on the size and location of the mass, either a partial or complete liver lobectomy will be performed. Pets can live safely without complications as long as less than 60% of the liver is removed. In some instances where the tumor is malignant (cancer), there will be obvious spread (metastatic) of the tumor to other areas or organs. In most cases, we will not know if the tumor is benign or malignant until the sample is examined by a pathologist under a microscope. The surgeon may want to contact you during surgery to discuss the findings so please be sure to have a phone nearby during the procedure. The surgeon will attempt to remove the entire mass but in some cases where this may not be done safely, a biopsy will be taken. Many liver tumors are benign hepatomas that grow very slowly and complete resection is not necessary. The biggest complication of liver surgery is hemorrhage both during and after surgery. Your pet may require a blood transfusion which is determined by serial blood counts taken for a few days after the surgery. This is more common in patients with large tumors. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Mass or tumor removals are not uncommon in dogs and cats. These can be tumors that grow in or around a major organ, subcanteously under skin or apart of the skin. These masses or tumors can be benign or malignant. A pre-surgical needle aspirate or biopsy is highly recommended so the surgeon can know how aggressive to be at the time of removal. Malignant tumors need a wider margin of excision than benign tumors and have a higher chance for recurrence or spread to other parts of the body. Unfortunately, sometimes it is impossible to get a definitive diagnosis without removing the entire tumor. Even with aggressive surgery, these tumors occasionally re-grow and need further surgery. Rarely, the tumor can be so invasive that complete excision is not possible without damaging the organ or the nerves that lie near the mass. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with a kidney disease that requires removal of the damaged kidney. There are many different diseases that can affect the kidney including infection (abscess), genetic conditions like polycystic disease, hydronephrosis where a ureteral blockage backs up urine into the kidney causing permanent damage from the pressure, avulsion or damage from trauma, kidney stones, and tumors (benign and malignant). Before removing a diseased kidney, it is important to run some tests (blood, urine, intravenous pyelogram, GFR measurements using nuclear scintigraphy exam or excretory urogram, ultrasound, etc.) to make sure that the remaining kidney is functioning sufficiently enough to maintain life. Dogs, like people, can live with one kidney with a normal life span. People donate kidneys all the time and the remaining kidney enlarges to compensate for the loss of the other kidney. If your pet has a malignant kidney tumor (most often determined from a biopsy specimen after surgery), it can spread undetected by the surgery to other organs and create medical problems in the future. Most of the time, removal of the kidney is curative. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with an OCD lesion that needs surgical repair. The goal of any orthopedic surgery is fast return to function of the injured joint. In most cases, there will be no complications and your pet’s joint will heal fully in 4-6 weeks. Unfortunately, in some cases, complications can arise, especially in our animal patients where bed rest and crutches are never an option. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with a luxating patella that needs surgical repair. Orthopedic surgery is a combination of both art and science and the orthopedic surgeon will evaluate your pet’s radiographs and determine the best method of repair given your pet’s age, extent of luxation, underlying joint confirmation, and the home environment for post-surgical rehabilitation. The surgeon may utilize one or more methods of repair depending upon the joint. This can include other torn or stretched ligaments, meniscal damage (cartilage), rotation of the tibial crest, and stretching of the joint capsule. The goal of any orthopedic surgery is fast return to function of the injured joint. In most cases, there will be no complications and your pet’s joint will heal fully in 8-12 weeks. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

My pet is having surgery today on the: *

Front Leg
Rear Leg
Left Leg
Right Leg

Your pet has been diagnosed with a perineal hernia that requires surgical repair. Perineal hernias result from weakening of the perineal muscles and external anal sphincter. The exact cause is unknown but any condition that causes chronic straining (constipation and an enlarged prostate common in dogs that are not neutered), hormonal imbalances, and degenerative changes to the levator ani musculature are thought to contribute. The objectives of the surgery are to replace the contents of the hernial sac into the abdomen and reconstruct the pelvic diaphragm. Many different surgical techniques are available to the surgeon but using the obturator muscle to close the defect is the most commonly utilized procedure due as it is associated with fewer problems postoperatively and a lower recurrence rate. On occasion, if your pet has very weak muscles, a synthetic Marlex mesh is used to rebuild the pelvic diaphragm. If your pet is not neutered, neutering is necessary to allow proper healing and prevent recurrence. Although every effort is made to prevent or minimize complications, any surgery near the rectum has a higher complication rate than other areas of the body. Besides the obvious issue of fecal contamination that can lead to infection, pets frequently lick or scoot after surgery which can irritate the incision or prematurely tear out any sutures. Additionally, bowel movements can be affected due to post-operative discomfort and many times your veterinarian may prescribe stool softeners for a short time until the surgical wound is healed. The urethra (tube that carries urine from the bladder) is very close to the surgical site and every effort is made to prevent inadvertent sutures from entrapping this structure including placing a urinary catheter in your pet before surgery. Additionally, the nerves that control the rectum are frequently involved in the hernia and all attempts are made to protect these nerves. Your pet can function adequately with loss of nerves on only one side of the rectum, but if your pet has bilateral hernias, there is the possibility of permanent nerve injury to the rectum. Although most surgeons will repair both sides at the same time if bilateral hernias are present, sometimes we will stage the procedure 4-6 weeks apart. The biggest complication of perineal hernia repair is recurrence. If your pet has a recurrence, there are several salvage procedures available to the surgeon. Remember that neutering your male pet at a young age dramatically reduces the incidence of perineal hernias. In some cases, your pet’s bladder may “retroflex” into the hernial sac causing a large swelling that may get bigger and smaller as the bladder empties and fills. Sometimes, the neck of the bladder can bend in a way that your pet can no longer urinate and this is a surgical emergency. If your pet’s bladder is involved in the hernia, it is very important to do an additional surgical procedure called a cystopexy, where the bladder is anchored inside the abdomen by one of two techniques depending upon the surgeon’s preference. Failure to perform this procedure increases the risk of recurrence many fold. Unfortunately, this adds expense and anesthetic time but if critical to a successful outcome. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with a blocked urethra that needs surgery. The success of this surgery depends upon a healthy urethra which can not be fully evaluated until it is looked at during surgery. In some cases, scar tissue or lacerations can affect the ability of the surgeon to perform the correction. In rare cases, if the damage is up inside the pelvic urethra, the bladder and urethra have to be exposed through an abdominal incision and a new opening created on the abdomen of your pet. Most of the time, though, a much simpler surgery is performed whereby a new urethral opening is created just under the anus which will make your pet look more anatomically like a female rather than a male. The surgery will entail amputating the penis along with the diseased part of the urethra and suturing the healthy urethra to the skin. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with a premature closure of a growth plate in the front leg. Because there are two bones that need to grow together, when one growth plate stops working it causes the leg to have “asynchronous” growth of the two bones. This causes the joints above and below the bone to form improperly and in many cases, a bowing of the leg. In growing animals we have to cut the bone with stunted growth in order to allow the limb to grow properly. If caught early enough, many times the joints will form normally and the bowing will straighten out without any loss of limb length. Unfortunately, in some patients, a second surgery is sometimes necessary after they finish growing to repair the angular deformity or shortened limb. In addition, some patients have so much damage to their elbow joint that despite our best attempts, some degree of arthritis may develop later in life. Orthopedic surgery is a combination of both art and science and the orthopedic surgeon will evaluate your pet’s radiographs and determine the best method of repair given your pet’s age, extent of deformity, and the home environment for post-surgical rehabilitation. The surgeon may utilize one or a combination of procedures to alleviate the deformities that exist but in most cases. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

You have elected to perform a prophylactic (preventative) technique on your pet due to the fact that a large percentage of deep chested dogs can develop a severe disease called gastic dilatation and volvulus (GDV). This disease presents acutely and can lead to possible death due to complications if not corrected surgically in timely fashion. Therefore, you have elected to surgically tack the stomach to the abdominal body wall in order to prevent the volvulus event (twisting of the stomach). This technique will not definitively prevent gastric distension, therefore, if pain is noted within the abdominal region, please see a veterinarian immediately. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with a salivary mucoele that requires surgical removal. These form as a result of a blockage, tearing, or infection of the duct leading from the salivary gland to the mouth. There are six different salivary glands on each side of the head and in most cases, the mandibular salivary gland is the one that is causing the problem. In some patients, tests may need to be done before surgery (or if the mucocele recurs) to determine not only which gland is involved, but which side is involved. We plan to remove the gland and either open the sac filled with saliva that has formed to drain or place a drain in the sac to be removed later. Depending upon where the sac is located (under the neck, under the tongue, back of the throat), different surgical techniques may be utilized. Since there are so many other salivary glands, dry mouth is rarely an issue. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with a diseased spleen that needs to be removed and/or biopsied. The spleen is not as critical an organ in pets as it is in people so the loss of a spleen does not shorten your pet’s life. The main function of the spleen is filtering the blood, and the liver will take over most of that function after the spleen is removed. The spleen also is involved in producing antibodies, but there is a lot of overlap with the liver, lymph nodes, and bone marrow so your pet will be fully able to fight off any future infections except blood parasites. Dogs may develop masses in their spleens. These masses can be benign or malignant, but because they are blood-filled, life-threatening bleeding can occur if they rupture. Surgical removal is usually recommended to find out the exact cause of the mass and to prevent or stop bleeding. Most splenic nodules are benign hyperplastic lymphoid nodules and/or hematomas. Some nodules are malignant tumors. Half of the tumors in the spleen are hemangiosarcomas, which are blood-filled malignant tumors of the spleen that rapidly spread to other organs. The rest are a variety of tumor types, with varying degrees of malignancy. Partial or complete removal of the spleen is the main treatment for splenic masses. In the immediate post-operative period, heart rhythm abnormalities may develop. Post-operative bleeding may occur. Removal of the spleen may make the dog more susceptible to certain blood parasites such as Ehrlichia canis. Many large vessels are ligated during splenectomy. There is a long abdominal incision. The dog must be kept quiet for 10-14 days after surgery to prevent bleeding or incisional problems. If your dog starts licking at the incision, a body sock or head collar may be recommended. In some instances where the tumor is malignant (cancer), there may be obvious spread (metastatic) of the tumor to other areas or organs. In most cases, we will not know if the tumor is benign or malignant until the sample is examined by a pathologist under a microscope. The surgeon may want to contact you during surgery to discuss the findings so please be sure to have a phone nearby during the procedure. Your pet may require a blood transfusion which is determined by serial blood counts taken for a few days after the surgery. This is more common in patients with bleeding tumors. Your surgeon is equipped with specialized US Surgical Autosuture TA stapling devices, Ligasure cautery devices as well as Hemoclips that are a safe and efficient way to do splenectomies, but in some cases, sutures may be used instead of staples. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with a chronic condition of the colon that requires a subtotal colectomy (removal of the colon). To relieve the constipation that is common with idiopathic megacolon, we must remove all of the diseased colon that is no longer functioning. The main job of the colon is absorption of fluid and storage of the stool. Remarkably, even though the small intestine will be connected to the small amount of remaining colon, your pet should have normal bowel function within a few months. The small intestine will undergo changes and take on the role of storage and fluid absorption over time. As with any surgery of the intestines, there are complications that can occur. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with a luxating superficial digital flexor tendon, whereby the tendon slides medially or laterally off the point of the tarsus. This injury occurs spontaneously during vigorous activity. This is a severe injury that if left unrepaired will result in a severe lameness. The longer the condition occurs and is unrepaired, the more likely for build up of fibrous/scar tissue and possible failure. Medical management with casts, splints or bandages alone is usually unsatisfactory. After 2-3 weeks of confinement and inactivity of the limb by placing the limb in a bandage and splint, the patient may receive controlled activity. This disease process is overrepresented in collie and Sheltie breeds. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with a torn anterior cruciate ligament that will benefit from a cora-based leveling osteotomy (CBLO) or tibial plateau leveling osteotomy (TPLO) procedure. Other techniques are available for treating this condition, however based on the size of your dog and the expected results of this procedure based on strictly following the recommended post-operative treatment protocol, your referring veterinarian and I believe the CBLO or TPLO procedure is most appropriate for your pet. To relieve the pain associated with the torn cruciate ligament and accompanying inflammation, the top portion of the tibia (lower leg bone) is osteotomized (cut) and rotated to a position that will produce less stress on the knee. Sometimes the medial and/or lateral meniscus (a shock absorber cartilage in the knee) is torn as well and must be removed or trimmed. When this cartilage is torn, arthritis develops more rapidly, even after removal. After surgery, your pet will need to go through periods of recovery to allow the bone to heal and rehabilitation to regain strength and flexibility in the affected leg. In most dogs, the recovery and rehab periods can be up to 4 to 6 months before full return to unrestricted activity. As with any surgery, there are complications that can occur. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

My pet is having surgery today on the: *

Left Leg
Right Leg

Your pet has been diagnosed with a torn anterior cruciate ligament that will benefit from a cora-based leveling osteotomy (CBLO) or tibial plateau leveling osteotomy (TPLO) procedure. Other techniques are available for treating this condition, however based on the size of your dog and the expected results of this procedure based on strictly following the recommended post-operative treatment protocol, your referring veterinarian and I believe the CBLO or TPLO procedure is most appropriate for your pet. To relieve the pain associated with the torn cruciate ligament and accompanying inflammation, the top portion of the tibia (lower leg bone) is osteotomized (cut) and rotated to a position that will produce less stress on the knee. Sometimes the medial and/or lateral meniscus (a shock absorber cartilage in the knee) is torn as well and must be removed or trimmed. When this cartilage is torn, arthritis develops more rapidly, even after removal. After surgery, your pet will need to go through periods of recovery to allow the bone to heal and rehabilitation to regain strength and flexibility in the affected leg. In most dogs, the recovery and rehab periods can be up to 4 to 6 months before full return to unrestricted activity. As with any surgery, there are complications that can occur. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

My pet is having surgery today on the: *

Left Leg
Right Leg

Your pet has been diagnosed with a torn anterior cruciate ligament that will benefit from a tibial tuberosity advancement) procedure. Other techniques are available for treating this condition, however based on the size of your dog and the expected results of this procedure based on strictly following the recommended postoperative treatment protocol, your referring veterinarian and I believe the Tibial tuberosity advancement procedure is most appropriate for your pet. To relieve the pain associated with the torn cruciate ligament and accompanying inflammation, the top portion of the tibia (lower leg bone) is osteotomized (cut) and advanced to a position that will produce less stress on the knee. Sometimes the medial and/or lateral meniscus (a shock absorber cartilage in the knee) is torn as well and must be removed or trimmed. When this cartilage is torn, arthritis develops more rapidly, even after removal. After surgery, your pet will need to go through periods of recovery to allow the bone to heal and rehabilitation to regain strength and flexibility in the affected leg. In most dogs, the recovery and rehab periods can be up to 4 to 6 months before full return to unrestricted activity. As with any surgery, there are complications that can occur. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

My pet is having surgery today on the: *

Left Leg
Right Leg

Your pet has been diagnosed with a ruptured ligament that needs surgical repair. Due to your pet’s size and activity level a ligament replacement called Tightrope will be utilized. Tightrope is placed across bone tunnels in the femur bone just above the knee and across the tibia and anchored with titanium buttons. Tightrope is currently reported to have less incidence of complications than TPLO and nylon lateral sutures. Surgery is not a “cure” for this injury but a method to stabilize the joint, alleviate pain, and slow down the progression of arthritis. If there are osteophytes growing along the joint ridges (osteoarthritis) or meniscal damage (cartilage), additional procedures may be done. The goal of any orthopedic surgery is fast return to function of the injured joint. In most cases, there will be no complications and your pet’s joint will heal fully in 8-12 weeks, although with this severe injury the joint will never be good as new. Unfortunately, in some cases, complications can arise, especially in our animal patients where bed rest and crutches are never an option. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been diagnosed with chronic ear infections that need surgical repair. You have elected to have a procedure called a total ear canal ablation (TECA) and bulla osteotomy. This surgery involves totally removing the horizontal and vertical ear canal, the ear drum, and the lining of the inner ear in order to relieve the chronic infections and discomfort your pet has been experiencing. Although the entire ear is being removed (not the ear flap), the nerves will still pick up some vibrations allowing very little residual hearing. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Procedure(s): *

TECA
Bulla Osteotomy

Your pet has been diagnosed with an inner ear infection, tumor, or polyp that needs surgical treatment. You have elected to have a procedure called a ventral bulla osteotomy. This surgery involves entering the inner ear through a small hole in the bone on the bottom side of the skull. The tumor or infection is cleaned out and sometimes a drain is placed. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

Your pet has been presented for a bilateral ventriculochordectomy procedure. The goal of surgery is to reduce the ability of your pet to bark at is current volume. Please be aware that although your pet should be improved after surgery, a small percentage of patients learn to bark immediately following the surgery due to airway dynamics unable to be controlled surgically. As previously mentioned some patients will retain the ability to bark immediately following surgery or sometimes within the first 12 months following surgery. I consent to the selected surgical procedure(s). *

I have read, understand, and consent.

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform the below-mentioned procedure. The nature of the procedure(s) has been explained to me and no guarantee has been made as to results or cure. I understand that there may be risk involved in these procedures. I consent to the administration of such anesthetics or tranquilizers as are necessary. *

I authorize.

Anesthetic Risks: (Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks). This surgical procedure has an increased risk of anesthetic complication due to the breed of the patients it is performed on. We do not anticipate any in your pet but, on occasion, the following can occur: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on very rare occasions, general anesthesia can result in death. *

I have read and understand the risks.

Surgical Risks Include: 1. Infection (less than 3%) which may require additional testing and medication at an additional cost. 2. Blood clots that can lodge in major organs causing stroke or rarely death. 3. Nerve injury which can be temporary or permanent (very rare) 4. Arthritis in future months necessitating additional surgery at an additional cost. *

I have read and understand the risks.

Surgical Risks: Approximately 15% of small animals with diaphragmatic hernia will die prior to surgery, and animals with diaphragmatic herniorrhaphy performed within the first 24 hours after an injury have the highest mortality rate (33%). Re-expansion pulmonary edema following re-oxygenation of chronically collapsed lungs is a major cause of perioperative death, particularly in animals with long-standing diaphragmatic hernias. Reperfusion injury, with the release of superoxide radicals which cannot be effectively scavenged, is thought to result in increased pulmonary capillary permeability and pulmonary edema. Spontaneous ventilation in the postoperative patient is assisted by maintaining the patient in a forequarters-elevated position and the appropriate use of analgesics. The prognosis for animals presenting with a traumatic diaphragmatic hernia is variable depending on other injuries incurred. Of the patients that survive to presentation, the timing of surgery will significantly affect prognosis. Animals that have surgery greater than 24 hours after trauma have a lower mortality rate than those having surgery within the first 24 hours owing to the resolution of shock after appropriate medical stabilization. The proper utilization of medical stabilization followed by surgical intervention results in an overall success rate of over 90%. The most common complication following surgical intervention is the development or persistence of pneumothorax. While complications can occur in the immediate postoperative period, most are transient and self limiting and will resolve with conservative therapy. *

I have read and understand the risks.

I authorize the surgeons and/or associates (Drs. Dosal, Franklin, Harper, Kiefer, and Souza) of Texas Specialty Veterinary Services, PLLC, to perform surgery and/or diagnostic procedures on my pet. I am also aware that Drs. Harper and Souza are board certified in large animal surgery only but have retrained in small animal surgery as well, therefore, offers their services to small animal clients and their animals. I have also been made aware that Dr. Franklin is small animal surgery residency trained but has not become board-certified. At this time, Dr. Franklin’s title is Practice Limited to Surgery. Dr. Dosal is a general practitioner who spent the last three years under Dr. Harper crafting his trade in small animal surgery as well as completing the Improve International Certificate Program in Small Animal Surgery. I understand that there are other board-certified surgeons in small animal available in the area. Dr. Keifer is a board certified small animal surgeon. *

I have read and authorize.

A cancellation fee of $500 will be charged if the procedure is canceled or rescheduled within 24 hours (not to include Saturday or Sunday as TSVS is closed on weekends) of the scheduled surgery date. *

I have read and acknowledge the cancellation fee.

Texas Specialty Veterinary Services (TSVS) and Texas Specialty Veterinary Services Rehab and Conditioning occasionally feature patients on its Facebook page, YouTube channel, other social media sites, and in publications (print or online). With your permission, we may share your pet's picture, video or story. This may, also, include "Graduation" photos from TSVS Rehabilitation and Conditioning programs offered with our certified Rehab technician, Kim Barrier. We may mention your pet by name, but never the owner’s name. TSVS would be grateful that you'll be helping other pets by educating pet owners, veterinary technicians, and veterinarians. *

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I do not consent to using my pet on social media or website.

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TSVS Surgical Release Form