MT. McKinely AH - Dental Release Form

1
Consent for Dental Care
Owner’s First Name
Owner’s Last Name
Phone
Email
Pet’s Name
Today's weight
2
I, the undersigned, certify that I am the owner/agent of the animal described above. I give Mt. McKinley Animal Hospital permission to perform anesthesia and the following procedures:
Clear
3
While there are risks associated with general anesthesia, be assured that Mt. McKinley Animal Hospital will take every precaution to minimize risk by always performing the following:

Physical exam prior to anesthesia

Multi-parameter monitoring (blood pressure, EKG, CO2, heart/respiratory/temp)

Intravenous (IV) catheter and fluid therapy

Preoperative and postoperative pain control injections

Endotracheal intubation and oxygen therapy

Injectable and inhalant anesthetics based on your pet’s age and specific medical needs
4
Pre-Anesthetic Blood ScreeningBecause no surgery is without risk, it is advisable to perform a pre-anesthetic blood screen prior to surgery. Our veterinarians are recommending this procedure in order to help assess your pet’s basic organ function before undergoing anesthesia and surgery. If any abnormalities exist, we will contact you before proceeding or take steps to minimize the anesthesia risks. Please select an option below. *Blood work is strongly recommended for dogs and cats over 6 years old*
Yes, I want my pet to have pre-anesthetic blood screening. (Additional cost beginning at $100)
No, I understand the risk of both the anesthesia and surgery and I DO NOT want a pre-anesthetic blood screen.
5
Dental ExtractionsThe health of the teeth cannot be truly assessed until they are cleaned and evaluated with a probe and/or with dental radiographs. Often, one or more of the teeth are diseased and may need to be extracted. By signing below, you understand that tooth extraction may occur. If there are other issues, we need to be able to reach you at the phone number(s) listed below. Please read and select an option below regarding permission for extractions
Please perform whatever procedures are necessary and extract any teeth that the doctor feels need to be removed.
Please perform ONLY the procedures that were estimated until I can be reached by phone. I understand that if I am unable to be reached, the veterinarians may be forced to recover the animal and deal with the issues at a later date with an additional anesthesia and surgical fee.
6
It is important that we have phone number where you can be reached if consultation is necessary while your pet is under anesthesia
Phone Number #1
Phone Number #2
7
I hereby authorize Mt. McKinley Animal Hospital to perform such diagnostic , therapeutic and surgical procedures as described above. The nature of such services has been described to me to my satisfaction. I realize that there are risks involved with any anesthetic or surgical procedure and that no guarantee or warranty can be made regarding the results or cure. I also authorize the hospital staff in an emergency situation, to follow through with such procedures as are necessary for the well being of my pet on a continuing basis until further communication with me. I have been given an estimate and understand that it is an approximation of planned procedures and the final bill may be more or less than this amount. I understand that I assume financial responsibility for all services rendered.
8
Owner Signature* This field is required.
Clear
9
Date* This field is required.
Date
Year
Month
Day
Should be Empty: