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SX Ortho Intake Form PT and PRP

Keith Blass, DVM, DACVIM (Cardiology)
Jacqueline Gest, DVM, DACVIM (Internal Medicine)
Ariel Kravitz, DVM, DACVS- SA, CVA (Surgery)
Carol Margolis, DVM, DACT (Theriogenology)
Victoria Kearns, LVT, CCRP, NCM, OACM (Rehab)
Riley Palmese, LVT, CCAT (Rehab)

Owner Name:

Address:

Pet's Name :

Patient ID:

Species:

Breed:

Color:

Primary Contact Person & Phone #:

Emergency Person & Phone #:

Breeding Counseling:

DIET, MEDICATIONS, & SUPPLEMENTS:

Brand and type of food currently eating:

When was the last time the patient ate?

Name of medications if on any and frequency:

Name of medications if on any and frequency:
A
B
If so, please list the names, doses and last time given?

What surgery is the patient here for and are there any special instructions?

Platelet Rich Plasma (PRP): Please indicate whether or not you would like PRP injected into the joint of your pet's surgical leg?

Platelet Rich Plasma (PRP): Please indicate whether or not you would like PRP injected into the joint of your pet's surgical leg?
A
B

If applicable: Indicate whether or not you would like PRP injected into the joint of your pet's non-surgical leg as well?

If applicable: Indicate whether or not you would like PRP injected into the joint of your pet's non-surgical leg as well?
A
B
I am aware that if additional injections take place in the future, additional charges may accrue.
Untitled multiple choice field
A
B
*I have discussed to my satisfaction the health status of my pet listed
above with Gold Coast Center for Veterinary Care.
*I understand in the event my pet’s heart and/or breathing stops (cardiopulmonary arrest), resuscitation efforts according to the advanced directive authorized below will be undertaken by the doctor(s) and/or staff of Gold Coast Center for Veterinary Care.
*I understand the doctor(s) and/or staff will immediately attempt to contact me via telephone at the telephone number(s) provided by me in the event of cardiac and/or respiratory arrest of my pet.
I request the following resuscitation effort(s) be implemented immediately by the doctor(s) and staff of Gold Coast Center for Veterinary Care (CHOOSE ONE):
Untitled multiple choice field
A
B
I voluntarily execute this order for my pet listed above and I understand its full import. I hereby authorize performance of the above surgical procedure. The nature of such service has been described to me to my satisfaction and I realize that no guarantee no warranty can ethically or professionally be made regarding the results or cure.
I understand that I assume financial responsibility for all services rendered, and that payment is due upon hospital discharge of patient.

Signature of Owner:

Signature

Date:

Physical Rehabilitation Authorization:
In order to ensure the health and proper care for all pets staying at our facility, I hereby give
permission for Gold Coast Center for Veterinary Care to perform Physical Rehabilitation on my pet.

List your name:

I also understand that Gold Coast Center for Veterinary Care is not responsible for any medical conditions or illnesses that may become evident in patient while he is here for Physical Rehabilitation.
In the event that such a condition is discovered, either during the exam or while rehabilitation is being performed, I may be contacted at the number indicated below.
I certify that no guarantee or assurance has been made as to the results that may be obtained and I accept the risks of patient treatment without liability to Gold Coast Center for Veterinary Care.
I understand that my signature below gives authorization for the full course of physical therapy required for patient authorizing from as few as one visit to multiple visits that may be needed for his rehabilitation.
I fully understand that all fees are due upon discharge and I agree to pay those fees. I am aware that I am responsible for all finances, collections, and attorney fees incurred if I do not pay these charges.
Photo/Video Release Form:
Gold Coast Center for Veterinary Care is asking for your consent to take photos/videos and possibly write about your pet’s story on our social media web pages, websites, and in our marketing.
These postings can help to further educate/promote awareness for the many types of treatments, success stories and interesting cases we see here.
*Note- Gold Coast Center for Veterinary Care will never share any of your personal, client information over the internet.
(Please check one)
Untitled multiple choice field
A
B

Signature of Owner or Authorized Agent:

Signature

Date:

Post-Operative Home Care Set Up Instructions

When your pet is discharged from the hospital, having your home set up and everything you need ready to can make a huge difference. Please read the following instructions below for proper home set up and a list of everything you will need.
Home Recommendations:
- Please set up a “safe zone” for your pet to be confined to during this recovery time. We typically recommend a small room with no furniture versus a plastic walled playpen. Your pet should not have free rein of the house.
- Slippery floors such as tile and hardwood should be avoided. Please keep your pet on tractioned surfaces at all times within the house. Traction surfaces meaning carpet, area rugs, runner carpets, yoga mat or interlocking puzzle mats.
- For the next 8 weeks, there should be no running, no jumping, no going on the couch, no
going on your bed. All activities should be on the floor.
- Please keep your pet away from other pet siblings at home. If they do need to have some interaction, please make sure it is in a controlled environment such as, someone holding the pet themselves and then saying “hi” to their sibling.
- For the next few weeks, please avoid stairs. If stairs cannot be avoided in the home, please utilize sling support to assist your pet.
Items you will need for post-operative care:
- Gel/moldable ice pack- ice pack will need to be large enough to wrap around the joint.
- Beanie microwaveable hot pack- hot pack needs to be large enough to be placed on the outside of the affected area.
Physical Rehabilitation Follow-up recommendations:
- Please make a 2-week follow-up appointment with the Rehabilitation Department for a treatment and some new exercises that can now be performed. Often, owners elect to make this a dual appointment and see the surgery and rehabilitation departments on the same day. Please speak with your Rehabilitator to make this appointment.