Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Woodside Equine Clinic P.O. Box 989 – 13011 Blanton Road – Ashland, Va. 23005 Phone: (804) 798-3281 Fax: (804) 798-2703 ADMISSION INFORMATION Owner Information Last Name: First Name: Are you a new or existing client: ☐ New ☐ Existing Referring Veterinarian: Address: City: Phone Number: Alternate Number: Email Address: State: Zip: Authorized Agent: Patient Information Name: Previous Patient: Breed: Color: ☐ Yes Sex: ☐ No ☐ Gelding Age: ☐ Mare/Filly ☐ Stud/Colt Admission Information Reason for Admission: Known Drug or Other Allergies: Vices: Current Medications: # flakes – AM Feeding: Type of Hay: # flakes – PM Qty. – AM Type of Grain: Qty. – PM Equipment/Supplies left with horse: Turn Out: : ☐ Yes ☐ No Turn Out Instructions: Admitting Veterinarian Admitting Veterinarian: Date Admitted: Cut --------------------------------------------------------------------------------------------------------------------------------- FINANCIAL RESPONSIBILITY Payment Information I, the undersigned, do hereby verify: that I am the owner (or the owner’s duly authorized agent) of the above described animal, that I have confirmed the accuracy of the information above, and that I hereby give my permission for the necessary procedure(s) to be performed. I understand the payment terms and agree to pay all charges and fees in accordance with these terms. I agree I will not hold Woodside Equine Clinic or any of its employees, owners, or agents responsible in case of injury and/or death related to any authorized procedures in connection herewith. Signature:__________________________________________________________ Date:_______________________________ Is Horse Insured: ☐ Yes ☐ No Insurance Company: Insurance Company Policy: Credit Card Information: Insurance Company Phone : ☐ Visa ☐ MasterCard ☐ Discover Credit Card Number: ☐ American Express Expiration Date: Name as it appears on credit card account: John Deere Financial Account Number (formerly Farm Plan) : Name as it appears on the John Deere Financial account: Authorized Signature: Print Authorized Signature: Deposit of 50% due at admission and balance due at time of discharge Revised 8/25/2011 13011 Blanton Road Ashland, VA 23005 Phone: 804.798.3281 Fax: 804.798.2703 www.woodsideequineclinic.com Surgical/Medical Release This is to document that the undersigned authorizes the surgical/medical procedure known as _____________________________________________________________ (Procedure) to be performed by one of veterinarians at Woodside Equine Clinic on: ___________________________________ (Horse) ___________________________________ (Owner) The advantages of this procedure, possible complications, as well as alternative treatment options have been adequately explained to me. The undersigned also authorizes one of Woodside Equine Clinic veterinarians to utilize any anesthesia deemed appropriate, and also to perform such additional procedures considered therapeutically necessary on the basis of findings during the course of the procedure. Is the above horse insured? Yes No If yes, has the insurance company been notified? We do not bill insurance companies. You will be required to pay the balance in full when the animal is released.______ (initial) A deposit is required for any surgical/medical procedure at admission to Woodside Equine Clinic. This deposit is to equal at least one-half of the estimated cost of the procedure and post-operative care. The balance will be due and payable when the animal is released. By signing this Surgical/Medical Release form you hereby agree to pay for any and all collection fees and/or legal fees incurred on the above said animal. Estimated cost of surgical / medical procedure and aftercare (uncomplicated) ___________________ Amount of required deposit ______________ Woodside Equine Clinic assumes no responsibility for loss of life while on the premises. Mortality coverage is the sole responsibility of the horse owner or client. I have been advised as to the nature of the procedures or operations and the risks involved or whether unknown risks occur. I realize that results cannot be guaranteed and understand the contents of this form. I have received the anesthesia fact sheet______ (initial) I acknowledge that all the professional fees for my horse’s proposed procedure have been explained to me and I am in agreement with the payment procedure. Signed__________________________________PrintName______________________________ Date/Time_______________________________Witness________________________________ 13011 Blanton Road Ashland, VA 23005 Phone: 804.798.3281 Fax: 804.798.2703 www.woodsideequineclinic.com Anesthesia Risks Fact Sheet - There are always some risks of general anesthesia and these risks are slightly higher in a sick/compromised patient. - Overall risk of death from complications under anesthesia is approximately 0.12%. - There is a low risk (less than 0.1%) of cardiac arrest during anesthesia. We take every effort to minimize this risk by using multiple monitoring devices during anesthesia and having highly-trained anesthetists. - There is a low risk (less than 0.1%) of catastrophic fracture during induction or recovery from anesthesia. We take every effort to minimize this risk by performing assisted recoveries with head and tail ropes in a padded recovery stall. - Post-anesthetic myopathy or neuropathy is muscle or nerve damage that can vary from being very mild to very severe. There is a low risk of this any time a horse is anesthetized. Risk increases linearly with heavier horses and longer duration of anesthesia. VISITATION POLICY 1. Visiting hours: Weekdays 10 a.m. to 7p.m. Holidays/Weekends 8 a.m. to 10 a.m. 2. If visiting during normal business hours, visitors must check in with the front office, who will then notify the attending doctor. You will be given a visitor’s badge, which must be worn at all times during your visit. You will then be escorted to your horse’s stall. • If you do not have a visitor’s badge, you will be asked to return to the front desk to obtain one. 3. All visitors must check out upon departure. 4. Visitation may be limited to one hour per visit. 5. Prior arrangements may be made with a doctor for after-hours visits. If visiting after hours (57pm on weekdays, 8-10am on weekends), there will be a sign in the entry way. You MUST call the number on the sign to speak with the technician on call BEFORE entering. 6. As an owner you will only be permitted to visit your horse. Contact with other patients is prohibited. 7. Owners are not to administer treatments without checking with the doctor involved with the case. 8. If your horse is in isolation, direct contact is not allowed. 9. For safety and sustained patient care, no visitation after 7pm. 10. Updates for Hospitalized patients will be available after 9am. Thank you so much for your cooperation! Signature: _________________________________ Date: _____________________ P.O. BOX 989 13011 Blanton Road ASHLAND VA, 23005 Phone: (804) 798-3281 Fax: (804) 798-2703 www.woodsideequineclinic.com DISCLOSURE OF CLINIC HOURS Woodside Equine Clinic’s hours of operation when licensed veterinary staff and licensed veterinary technicians are present on property are: Monday – Friday 8:00 a.m. to 5:00 p.m. Saturday – Closed Sunday – Closed Where holidays are involved, the clinic is closed with limited staff on duty. Woodside Equine Clinic is staffed 24 hours a day for all hospitalized cases requiring treatments. A veterinarian or licensed veterinary technician, and/or a veterinary assistant will be assigned to monitor and treat patients as required. Visitation after-hours requires prior arrangements. Please call our clinic or speak to your veterinarian for arrangements. _________________________________ Client Name (Please Print) __________________________________ Client Signature ___________________________________ Date 13011 Blanton Road Ashland, VA 23005 Phone: 804.798.3281 Fax: 804.798.2703 www.woodsideequineclinic.com Colic Surgery Fact Sheet Cost estimates: -Emergency large intestinal colic sx:$7,500.00-9,000.00 without complications. -Emergency small intestinal colic sx:$9,000.00-11,000.00 without complications - The estimates typically encompass everything from arrival to departure from WEC. - We will talk with you about finances if complications arise that will increase the cost. Risks of general anesthesia: - There are always some risks of general anesthesia, and these risks are slightly higher in a sick/compromised patient. Overall risk of death from complications under anesthesia is approximately 0.12%. - There is a low risk (less than 0.1%) of cardiac arrest during anesthesia. We take every effort to minimize this risk by using multiple monitoring devices during anesthesia and having highly-trained anesthetists. - Any time a horse is anesthetized there is a low risk (less than 0.1%) of catastrophic fracture during induction or recovery from anesthesia. We take every effort to minimize this risk by performing assisted recoveries with head and tail ropes in a padded recovery stall. - Post-anesthetic myopathy or neuropathy is muscle or nerve damage that can vary from being very mild to very severe. There is a low risk of this any time a horse is anesthetized. Risk increases linearly with heavier horses and longer duration of anesthesia. The surgical procedure: - The horse will be placed under general anesthesia on his/her back on the surgical table. After routine clipping and sterile cleaning, a surgical incision varying from 25-40 cm in length will be made along the belly. The abdomen will be thoroughly explored and the problem assessed. If the cause of the colic is routine and not likely to change the prognosis, we will continue with surgery. If the cause of the colic and surgical treatment changes the prognosis, we will talk with you during surgery. Typical length of hospital stay: - If there are no complications, most horses go home 5-7 days after surgery. Prognosis: - Overall survival rate for horses after colic surgery is approximately 83%. - Approximately 90% of horses with large intestinal problems survive, and approximately 75% of horses with small intestinal problems survive. - Most horses without complications return to normal level of work (jumping or roping etc.) 3 months after surgery. Some possible complications after surgery: - Ileus, or lack of return of intestinal motility, is the most common short-term complication, and some degree of this occurs in approximately 6-20% of horses after colic surgery. It is more common in horses that had small intestinal problems than large intestinal problems. - Adhesion formation occurs in approximately 5% of horses after colic surgery, and in up to 22% of small intestinal surgeries. An adhesion is when two parts of the abdomen adhere inappropriately as a result of intra-abdominal inflammation. This can potentially cause a blockage of intestinal contents or create a place for intestine to get trapped. It can cause colic within days to years after surgery, but most problems occur within 2 months. - Incisional infection occurs in approximately 25% of horses. It can develop days to weeks after surgery and signs can include fever, discharge from the incision, and increased swelling at the incision. - Incisional hernia occurs in approximately 16% of horses. It is approximately 18 times more likely in horses that have had incisional infections or multiple colic surgeries. - This is obviously not a comprehensive list, but it covers the most likely complications. Some other possible post-operative complications that are slightly less common include diarrhea, laminitis, and jugular vein thrombosis.