Anesthetic Release - Comprehensive Oral Health Assessment and Therapy

Anesthetic Release - Comprehensive Oral Health Assessment and Therapy

Please fill out this release form in it's entirety.
Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Pet's Name*
Appointment Date*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Alternate Phone Number*

Area CodePhone Number
Admission for COHAT of dental condition grade:
To be filled out by veterinary team
Please read and understand the following topics regarding the welfare of your pet while he/she is admitted into our care today:

1. I am over the age of 18 and am the owner or appointed liaison fo the patient indicated above.

2. I understand that if the above named pet has fleas a medication will be given at an additional charge.

3. I understand that in order for a procedure requiring anesthesia or sedation to be performed safely an intravenous catheter will be placed in my pet using aseptic technique to ensure reliable venous access for the purposes of pain management, sedation, antibiotic therapy, fluid support and possible emergency intervention.

4. I accept that an initial medical treatment plan will be reviewed with me by a veterinary technician where the medical and financial aspects of this anticipated treatment plan will be agreed upon prior to admission of my pet into the hospital for the above indicated procedure.

5. I agree to pay, in full, for services rendered while my pet is hospitalized prior to him/her being discharged. This includes any fees related to services deemed necessary for my pet in the occurence of a medical/surgical emergency or change in medical thrapy plan due to unforeseen circumstance.

6. If an emergency situation may occur and I am unreachable immediatley at either of the above listed contact phone numbers I authorize the attending veterinarian to proceed with medical care under their judgment and my CPR directive below.

7. I acknowledge that no gurantees can be made regarding medical diagnosis, intervention, therapy and recovery plans pertaining to my pet except that reasonable precautions against, injury, escape, illness and death will be taken while hospitalized.

8. I understand that my pet's true dental health condition can only be revealed during this anesthetic procedure through the aide of a conprehensive oral exam and completion of full mouth dental radiographs. Once the full assessment has been done, the attending veterinarian may need to perform oral surgery to treat and/or correct any oral health deficits including, but not limited to tooth extractions, growth removals, etc., that will directly benefit the health and comfortable dentition of my pet. The attending veterinarian is hereby authorized to perform such necessary medical therapies discussed in the medical treatment plan or other wise.

9. I understand that there are risks associated with any procedure that requires anesthesia or sedation and I have spoken to the veterinarian regarding my concerns related to those risks that include, but are not limited to injury, illness and death. I accept the risks associated with my decision to have the above indicated procedure performed on my pet. I do not hold Sacajawea Healthcare for Pets, its doctors, staff or associated entities responsible for any unforseen outcome related the procedure being performed on my pet today.
Signature*

Clear
CPR Directive:
In the event of an unforeseen medical emergency that may require life saving measures to be taken while my pet is in the care of Sacajawea Healthcare for Pets, I direct the following emergency option:*

Full CPR (Cardio Pulmonary Resuscitation) Measures : I understand there are fees associated with initiating such medical intervention that can quickly contribute an estimated $700-$900 to my pet's medical invoice of services. I will be responsible for these fees regardless of the outcome of life sustaining measures.DO NOT RESUSCITATE: No extensive intervention (CPR) measures will be taken in the event of cardiopulmonary arrest.
Signature*

Clear
Our team will make every effort to contact you during the procedure indicated above if further treatments are needed that were not a part of the initial treatment plan. In the event that you cannot be reached:*

I authorize the attending veterinarian to perform all treatment recommended including treatments not included in the initial treatment plan. I understand that I will be responsible for all costs related to these treatments.I authorize the attending veterinarian to perform treatment not to exceed $300 above the treatment plan that was presented to me. I understand that by choosing this option my pet may need to have a second procedure performed to complete treatment and I will be responsible for all costs related to a second procedure.I authorize the attending veterinarian to perform only treatments discussed with me on the initial treatment plan that was presented to me. I understand that by choosing this option my pet may need to have another procedure performed to complete treatment and I will be responsible for all costs related to a second procedure.
I have fully read, understand and agree to the above statements.*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
What date and time was the last meal for your pet?*
Has water been available to your pet in the last 8 hours?*

YesNo
List any medications (including flea prevention) your pet is currently taking and the last time they were given.*
Does your pet have any food or environmental allergies you are aware of?*

YesNo
Has your pet recently had any of the following?*

vomitingdiarrheastarted/worsening cough or sneezelethargyitching/scratching/scootingNone of the above
Please list when the occurrences happened and the duration.*
Has your pet traveled outside of the Puget Sound area withing the last 6 months?*

YesNo
If yes, please list where, when and how long your pet was outside the area.*
Has your pet been seen by any other veterinarian in the last 6 months?*

YesNo
Name and phone number of other veterinarian*
Should be Empty: