Informed Consent Template, Pyometra

Based on the professional guidelines and clinical frameworks provided in the sources, an informed consent template for a veterinary clinic—particularly one practicing Spectrum of Care (SOC) or Incremental Veterinary Care (IVC)—should document the dialogue between the provider and the client regarding diagnostic and treatment options, associated risks, and financial obligations.

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Informed Consent for Veterinary Care

Patient Name: ____________________  Species/Breed: ____________________ Client/Authorized Agent Name: ____________________  Date: ____________________

1. Clinical Situation & Options

The veterinarian has explained the patient’s current medical condition, including a provisional diagnosis and the potential for that diagnosis to be revised as more information becomes available.

We have discussed a range of evidence-based care options tailored to my goals, resources, and my pet’s unique circumstances. These options include:

• Path A (High Resource/Gold Standard): Comprehensive diagnostics and intensive treatment. Patient will be transferred to a specialty hospital, and/or emergency facility for care. Cost of care is not expected to be beyond clients ability. Estimates can range from $4,000 to over $10,000.

• Path B (Incremental/Nonspecialized): Tiered diagnostic and therapeutic steps focused on the most pressing health issues and patient comfort. Care may be given here at Jarrettsville Veterinary Center, or your pet will be referred to another general care, or, procedure clinic. It is understood that there will not be 24 hour, or, overnight care provided.

• Path C (Stabilization/Palliative): Minimal intervention focused on pain control and quality of life. The patient will be provided subcutaneous fluids, antibiotics (injectable and oral) and analgesics (injectable and oral) and go home to be cared for. This may include transfer to another facility in the coming days. It is at the veterinarians discretion, and based on local/state/federal laws that this patient may be forwarded to appropriate animal control guidance for after care and follow up.

2. Risk Assessment & Uncertainty

I understand that:

• Every procedure, including anesthesia and surgery, carries inherent risks of complications or death.

• Choosing an incremental approach (Path B or C) may involve skipping certain diagnostic tests, which could result in a level of clinical uncertainty or a different outcome than the gold standard.

• The treatment plan is dynamic and may need to be revised based on my pet's response to therapy.

3. Financial Estimate

I have received a line-by-line itemized estimate of the charges for the chosen services. I understand I am responsible for these costs, including any recommended follow-up rechecks within 24–48 hours.

4. Emergency & Unexpected Procedures

In the event of an emergency or unexpected finding during a procedure:

• [ ] The veterinarian has my permission to perform life-saving measures up to $________.

• [ ] The veterinarian must call me at ____________________ before proceeding with any additional treatment.

5. Special Protocols (If Applicable)

• Community Cats: I authorize eartipping and the use of dissolvable sutures.

• Euthanasia: If a poor prognosis is confirmed during exploratory surgery or if the pet is suffering and no further care is possible, I authorize humane euthanasia.

6. Authorization

I confirm that the information provided has been explained in a manner I understand. I have had the opportunity to ask questions, and I consent to the recommended treatment plan.

Client Signature: ________________________________________ Veterinarian Signature: ________________________________________