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Cystotomy Consent Form

Save time during your next appointment! Complete your required forms online from any device at any time before your scheduled appointment.

“Bringing specialized veterinary surgical services to you!”

Jacqueline J Mair
DVM,MBA, Diplomate ACVS

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mss - cystotomy

Cystotomy Consent Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before the procedure.

Date *

Client Details

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Secondary Phone

Email *

Animal Details

Name *

Species *

Cat
Dog

Breed *

Age *

Sex *

Male
Neutered Male
Female
Spayed Female

Weight *

Your Pet has been admitted for None Specified

Has your pet eaten after 8pm last night? *

Yes
No

Has your pet had any medication recently? *

Yes
No

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 stones may be prevented or managed with diet; some types calcium oxalate, cystiene, biurate will recur. 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 *

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

I hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform this 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). The incidence of complications from anesthesia is extremely low and we do not anticipate any in your pet but on rare occasions 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. Recurrence of stones may occur when there is no treatment for prevention as in cystiene, calcium oxalate stones, ammonium biurate. 4. Some male does with urethra obstruction that cannot be relieved with retropulsion of the stones will need to have a scrotal urethrostomy to open the urethra above the obstruction. These dogs must be neutered. This procedure will lead bleeding for several days after surgery. 5. Blood in the urine is normal for 3-6 days after surgery. *

I have read and understand the risks.

NOCITA (bupivacaine liposome injectable suspension) is a long-acting, local anesthetic that provides up to 72 hours of post-operative pain relief by releasing bupivacaine (anesthetic pain relief agent) over time from multi-vesicular liposomes. Dr. Mair is happy to provide this additional form of pain medication during surgery for your patient if you would like to do so. Nocita is labeled For single-dose infiltration into the surgical site to provide local postoperative analgesia for cranial cruciate ligament surgery (TPLO, Extracapsular repair, etc) in dogs and as a nerve block in cats for declaw procedures. Like many drugs in the veterinary space that are used commonly but not specifically labeled for veterinary medical usage, we offer Nocita usage for pain control for our surgical patients off label to be used where deemed appropriate and safe. *

YES - I approve to have Nocita used at the time of surgery on my pet for pain control understand that in select instances it may be used off label when deemed safe by Dr. Mair. Please check with your regular veterinary clinic if it is already included in your estimate. If not included in your original estimate, generally a single dose of Nocita runs $200-$400.
NO - I do not approve Nocita pain control for my pet’s surgery.

I authorize Dr. Jacqueline Mair, DVM, DACVS-sa, MBA to perform surgery on my pet. Dr. Mair is a board certified small animal surgeon. *

I have read and authorize.

A cancellation fee equal to the surgery fee will charged if the procedure is cancelled less than 72 hours of scheduled surgery date. *

I have read and acknowledge the cancellation fee.

If anesthesia/sedation is required, I understand that there are risks involved and that in the event of an emergency, the hospital will take all necessary actions to control the problem and will notify me as soon as possible. I understand and agree to the use of human medicine in my animal when deemed appropriate by the Veterinarian. The estimated cost of these procedures is provided by Jacqueline J Mair DVM, DACVS, MBA I fully understand that this is an estimate only. Jacqueline J Mair DVM, DACVS, MBA makes every effort to remain within the estimate given. I agree to meet the costs of all treatment at the time of discharge. I understand the risks and complications of these procedures, which have been explained to me by the Veterinarian. All accounts are payable at the time of consultation unless a prior arrangement has been made. *

Clear Signature

Signed by: *

Owner
Agent

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