Page 3327 - Cote clinical veterinary advisor dogs and cats 4th

Consent to Perform Microchip Implantation

VetBooks.ir Patient name:_________________________________
Pet owner’s name:_____________________________ Med rec #____________
Best contact during/after procedure (e.g., cell phone number):____________________

INTRODUCTION It is up to the individual owner to maintain an accurate address
We want to make sure that you understand the planned medical and phone number(s) with the microchip company in order to
procedure to be performed on your pet. You should know why the maximize the benefit of microchip placement.
procedure has been suggested, what the potential benefits are for
your pet, and the most common/important risks of the procedure. Other anticipated risks specific to your pet:___________________
Alternatives to this procedure, when applicable, will be discussed
with you. It is also important that you recognize that medicine is _________________________________________________________
not an exact science, and that the outcome cannot be guaranteed.
We encourage you to ask us as many questions as required for
you to make a well-informed decision. ALTERNATIVES TO THE PROCEDURE
Some owners will elect to use a collar with tags to identify their pets,
BENEFITS/OPTIMAL OUTCOME OF THE PROCEDURE though these can become damaged and fall off. Other methods of
An electronic microchip will allow for identification of your pet, identification that are less commonly used include tattooing or branding.
even without a collar or other outer identification methods. The
microchip, which is about the size of a grain of rice, is implanted AUTHORIZATION
underneath the skin on the back of the neck. If you lose your pet By signing this form below, you agree that:
and s/he is found, any animal shelter or veterinarian can use a • You understand how/why the procedure is likely to help your pet
scanning device to locate the microchip. This allows them to contact • You understand what will be done to your pet during the
the manufacturer of the device and find the contact information procedure
that you have provided. The microchip can also be used to prove • You understand the known risks that accompany the procedure,
ownership of a pet in case it is stolen or lost. and also understand that unforeseen complications may occur
• You understand that the procedure may not produce the results
EXPLANATION OF THE PROCEDURE we hope to achieve
Your pet will be restrained and the skin between the shoulder blades • You understand the alternatives to this procedure for your pet
will be tented up. A large single-use needle pre-loaded with the • You agree that you have been given time to ask questions regard-
microchip will be inserted under the skin and the attached syringe ing the procedure, that these have been answered satisfactorily,
used to push the microchip out of the needle. Once the microchip and that you are free to decline the procedure.
is in place, the needle will be removed and gentle pressure applied
to the skin at the injection site. The microchip will then be scanned
to ensure that it is readable on the microchip scanner. ____________________________________ ______________
We can help you register your contact information with the
microchip manufacturer. If in the future you have a change in address Signature of pet owner/owner’s agent Date
or phone number, or if your pet is adopted by a new owner, the
contact information should be updated. ____________________________________ ______________
Additional procedures planned for your pet at the same time
as the microchip implantation: Witness to consent (signature) Date
____________________________________________________________ ____________________________________

USE OF SEDATIVES OR ANESTHESIA Witness to consent (printed name)
No sedatives or anesthetics are utilized for this procedure. The
discomfort from the insertion of the needle containing the microchip
is minimal, similar to a vaccination.
FORESEEABLE RISKS TO THE PROCEDURE
Transient discomfort from needle insertion, bleeding, migration of the
microchip, or microchip malfunction/lack of detectability by some
microchip scanners are all minor risks of the procedure. Another
important risk is a lack of updated information in company’s information
system that might make it difficult to contact you if your pet is found.
Extremely rare (individual) cases of tumors at the microchip site, and
of spinal cord damage from the microchip, have been recorded.
Practice Stamp or Name & Address
Also available in Spanish.

From Cohn and Côté: Clinical Veterinary Advisor, 4th edition. Copyright © 2020 by Elsevier Inc. All rights reserved.