Surgical Consult Consent in West Texas | West Texas Veterinary Specialists

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OWNER & PATIENT INFORMATION

Owner / Authorized Agent*

First Last

Phone (Day of Surgery)*

Email*

Patient Name*

Species/Breed*

Age*

Sex*

HOSPITAL INFORMATION

Referring Veterinary Hospital

Referring Veterinarian

Surgery Location (Host Hospital)

Date of Surgery

PLANNED SURGICAL PROCEDURE(S)

Please describe*

AUTHORIZATION FOR SURGERY

WTVS and their collaborating board-certified surgeon, to perform the above-listed surgical procedure(s) on my pet at the host hospital listed above.

I understand that my pet has been referred from another veterinary hospital for specialty surgical care and that the surgery is being performed at a different facility than my primary veterinary clinic.

ROLE OF EACH PARTY

My primary Veterinary-Client-Patient Relationship (VCPR) remains with my referring veterinary hospital.
The host hospital is providing the facility and nursing support for the procedure. – WTVS and their collaborating surgeon provides specialty surgical services as a consulting surgeon.
West Texas Veterinary Specialists (WTVS) coordinates specialty services and communication and does not replace my primary veterinarian.

RISKS, COMPLICATIONS & MEDICAL JUDGMENT

I acknowledge that all surgical and anesthetic procedures carry inherent risks, including but not limited to infection, bleeding, delayed healing, implant complications, anesthetic complications, and, in rare cases, death.

I understand that no guarantee or warranty can ethically or professionally be made regarding the outcome of surgery or a cure.

If unexpected findings or complications arise during surgery or hospitalization, I authorize Dr. Thompson to use her professional judgment to provide reasonable and medically appropriate treatment. I understand that I will be contacted when possible if additional procedures or changes in treatment are required.

POSTOPERATIVE CARE & FOLLOW-UP

I understand that postoperative instructions regarding activity restriction, medications, incision care, monitoring, and recheck recommendations will be provided.

I acknowledge that strict adherence to postoperative instructions is essential to minimize complications and optimize outcome.

I understand that postoperative rechecks and long-term medical management will generally be coordinated through my referring veterinary hospital unless otherwise directed.

INDEPENDENT CONTRACTOR DISCLOSURE

I understand that all board-certified veterinary surgeons are private contractors and are not employees of West Texas Veterinary Specialists (WTVS), the referring hospital, or the host hospital.

FINANCIAL RESPONSIBILITY

I acknowledge that I am financially responsible for all charges related to my pet’s surgical care. I understand that estimates are not guarantees and that additional charges may be incurred if complications, additional procedures, or extended care are required.

CONSENT & RELEASE

I certify that I am the legal owner or authorized agent for this patient. I have read and understand this consent, have had the opportunity to ask questions, and agree to the terms outlined above.

Printed Name*

First Last

Owner / Agent Signature*

Date*

Best Phone Number for Today*

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Questions about how specialty care with WTVS works?

Visit our Frequently Asked Questions for information on referrals, scheduling, and what to expect.