Name: SURGE DVM
Price range: $

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 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.

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 cancelled 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. *

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

I authorize and understand by verbal consent and written consent the above information. *

I authorize and consent.

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Surgical Release Form

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