Download Hospital Admission Release

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.