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

I hereby authorize Angel Thompson, DVM, DACVS-SA, operating through AT Veterinary Surgical Services, PLLC, 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. – Dr. Thompson is providing 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 Dr. Angel Thompson practices independently through AT Veterinary Surgical Services, PLLC, and is not an employee 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.