Surgical Authorization Form NEW

Surgical Authorization Form

Authorization Form must be completed 48 hours prior to your pet's appointment
Owner / Agent's Name *

First Name Last Name
Pet's Name *

First Name Last Name
Phone Number (day of surgery) *

Area Code Phone Number
Email (day of surgery) *
Example: nyvp@biscuitsandbath.com
Please initial agreeing that your pet has / will not have anything to eat or drink past midnight (12am) the day of the Surgical Procedure *
Anesthetic and Surgical procedure(s) to be performed* *
Select One
Wellness Services
Are there any same-day wellness services you would like us to perform? *

Annual Urinalysis - assess the health of the kidneys and urinary system, but it can also reveal problems in other organ systems, and is important for diagnosing metabolic disease such as diabetes. ($96) Microchip - Permanent ID (size of a rice) under your pet's skin used for identification and ownership if pet is lost or within the incorrect household. ($67 with Surgery) Annual Heartworm / Tick-disease Screening - 4DX ($98) None
Anesthetic Procedural Information
Overview: There will be a pre-operative examination (anesthetic blood profile) for your pet to ensure there are no existing health conditions that could possibly lead to complications during the procedure, regardless of your pet’s last exam with NY Veterinary Practice. The blood profile checks for an adequate number of red and white blood cells, platelets, and checks proper function of the kidneys and liver, which may not be evident during a physical exam.

Pain Control/Medication: Will be given to your pet as needed. Animals undergoing surgical procedures will generally receive pain medication while in the hospital and additional medications to be sent home.

Monitoring: We further minimize anesthetic risk by monitoring heart rate and rhythm, respiration rate and quality, blood pressure, oxygenation, and depth of anesthesia during the procedure.

Catheterization: For most surgical procedures, an intravenous catheter is placed to provide us with an easy route to administer medications and fluids (which support kidney function and blood pressure) during the procedure.
Drop off / Pick up
Drop off: At Surgery location by 9am. If we are providing transportation for your dog, drop-off by 7:00am.

Pick up: At Surgery location after 5pm. If we are providing transportation for your dog, our driver will arrive between 6:00-7:00pm.
Surgical Procedure Information

The items listed below are included at no additional price
1. Pre-operative blood work & exam – To make sure your pet is healthy enough to undergo the anesthesia necessary for the procedure. While modern anesthesia is considered very safe this is a precautionary measure to minimize any risks
2. Monitoring vitals during procedure - These vitals include respiration rate, heart rate and rhythm, blood pressure, blood oxygen levels, and body temperature
3. Pre- anesthetic sedation - to relax and calm the patient and decrease the levels of anesthesia needed
4. Intravenous catheter placement and intravenous fluids
5. Anesthesia & monitoring - a gas anesthetic is used
6. Surgical Procedure
7. Peri-operative pain medication
8. Monitored Recovery
9. E-collar (cone collar) – To be worn after operation for 7-10 days (spay/neuter only)
10. Pain medication/Antibiotics – To take home after the surgery if medically necessary
11. Post-Surgical Re-check – 7-10 days virtual or in office appointment as needed
CPR Procedure Authorization
In the event that my companion animal arrests while under the care of NY Veterinary Practice I authorize the following CPR code (select one) *

DNR (DO NOT RESUSCITATE - No Resuscitation) CPR (Involving chest compression's, oxygen therapy, and medications such as epinephrine, atropine, etc.)
Signature *

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Payment & Cancellation Policy
Procedural prices are estimates - Unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or different procedure(s) than those set forth above, thus causing a difference in pricing.
Dental/Extractions - Cleaning does not include extractions– teeth will be extracted at the discretion of the doctor and are extracted only when necessary. Non-removal can adversely affect your pet’s health. Extraction of teeth, depends on the type of tooth ranging with additional fees between $60 to $275 per tooth.

Many animals have diseased teeth from periodontal disease, or from enamel erosions. These teeth are painful and should be extracted. Often, we will not discover the damaged teeth until a dental exam is performed while your pet is under anesthesia.
Neuters - There are additional costs associated for pets that have undescended testicles, over eight months, or over 50 lbs.
Spays - There are additional costs associated for pets that are in heat, over eight months, or over 50 lbs.
- All payments must be via credit card
- If you cancel with less than 48-hours notice you will be charged a $50 cancellation fee
- All in-office appointments will be charged an additional $25 COVID-19 supplemental fee
Call or email our medical team if you have any questions regarding your pet(s) upcoming surgery.

(646)-480-5089

nyvp@biscuitsandbath.com
Surgical Authorization Acknowledgment

By signing and printing my name below, I have agreed and acknowledge the entirety of this form.
I am the owner/agent for the pet receiving the surgery/procedure, and I authorize and request the services selected and discussed above. I have indicated any additional services I would like performed above. I understand that during the performance of the foregoing procedure(s), or operation(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or different procedure(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarian's professional judgment.

I also authorize the use of appropriate anesthetics; other medications and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. The nature of the procedure(s) has/have been explained to me and no guarantee has been made as to the results or cure. I understand that there may be risks involved in some of these procedures.

I agree to pay, in full, for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. Any estimates or charges for the planned procedures are only approximations, and the final bill may be greater or less than these amounts. All services must be paid for in full when your pet(s) is released.

I authorize the extraction of damaged teeth and administration of any medications that may be necessary while my pet is undergoing the dental cleaning procedure (if applicable).

I have read and understand this authorization and consent and agree to all of its terms and conditions.
Owner / Agent Electronic Signature *

Clear
Date *

Month Day Year
Date Hour Minutes AM/PM Option
Should be Empty:

Surgical Authorization Form

Wellness Services

Anesthetic Procedural Information

Drop off / Pick up

Surgical Procedure Information

CPR Procedure Authorization

Payment & Cancellation Policy

Surgical Authorization Acknowledgment