Dental Anesthesia Consent

Name *

First Name Last Name

Pet's Name *

Date of Procedure *

Best number to reach you at on the day of your pet's procedure: *

Area Code Phone Number

When did your pet last eat? (Pets should not eat after 8 PM the night before an anesthetic procedure) *

Does your pet have any known allergies? *

All pets presented for surgery must have current Rabies Vaccinations. Dogs must also have current Distemper, Kennel Cough and Influenza Vaccines. A copy of a current Rabies Certificate or confirmation by telephone from the Veterinarian administering the vaccination is required. A Rabies tag is not acceptable. (Initial) *

Any Animal found to be harboring external or internal parasites will be treated at the owner’s expense. (Initial) *

In the past 48 hours, please select if your pet has experienced any of the following: *

Coughing Sneezing Vomiting Diarrhea None of the above

Is your pet on any medications, if so, please list the medications and when they were last given. *

Do you have any additional concerns for the doctor today? *

If extractions are required, pain medication may be recommended for your pet. If gum disease is found, antibiotics may prescribed for you pet. These medications will be dispensed at an additional cost. (Initial) *

Please select any services you would like performed while your pet is under anesthesia:

Nail Trim (Complimentary) Nail Trim with Dremmel ($30.00) Anal Gland Expression ($31.50) Microchip ($45.00) Pre Op EKG ($39.90, prior to any sedation and included in Paw Plans)

In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedures today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference: *

Please proceed with life-saving measures. I will accept responsibility for all costs incurred regardless of my pet's survival. Please do not proceed with life-saving measures. I accept responsibility for all costs incurred regardless of my pet's survival.

In order to perform these dental procedures, your pet will be placed under general anesthesia. In some cases, we discover that extractions are necessary in the course of the procedure. These extractions will be done only if, in the opinion of the Veterinarian, they are medically necessary. Do we have your permission to perform these extractions? Please select one of the following: *

Please perform any extractions that the doctor deems necessary. Our goal is to keep within your estimate, however, the nature of dental care is such that we cannot predict everything that may need to be done beforehand. As a result, it is possible for your bill to vary considerably from the original estimate. Please call before performing any extractions. If I am not available, I give permission to do what is necessary. Again, your goal is to keep within your estimate, however, the nature of dental care is such that we cannot predict everything that may need to be done beforehand. As a result, it is possible for your bill to vary considerable from the original estimate. Please call before performing any extractions. I understand that if I am not available, no procedures will be performed without my authorization, even if deemed necessary.

Our greatest concern is the wellbeing of your pet. Before any anesthesia is administered, we will perform a complete pre-anesthetic examination to identify existing medical conditions that could complicate the procedure and compromise your pet’s health. There is always the possibility that a pre-anesthetic exam alone will not identify all health problems. This is why blood testing is required prior to anesthesia. This does not guarantee the absence of anesthetic complications. It may, however, greatly reduce the risk of complications as well as identify medical conditions that could require treatment. Preanesthetic Bloodwork: This panel includes: red blood cell counts, white blood cell counts, platelet counts, and a check on kidney and liver function. Some higher risk patients may require more comprehensive panels. If your pet has not had bloodwork performed and reported as ‘normal’ prior to their scheduled anesthesia/sedation, this test will be run the morning of their procedure. I, (or agent acting on owner’s behalf) hereby authorize Cape Fear Animal Hospital (or its agents or whomsoever is designated) to perform the above procedure. I understand that there are inherent risks with anesthesia and that a guarantee of a successful outcome cannot be made. These risks have been explained to me as completely as possible within reason. I also understand that Cape Fear Animal Hospital will do their best to minimize these risks through pre-anesthetic blood testing, using the most appropriate and safest anesthetics available, IV fluids to maintain blood pressure, and by using state of the art monitoring equipment. Furthermore, I agree to pay the fees for all services rendered at the time the pet is discharged from the hospital. Please sign recognizing that you have read and understand the risks.

Email

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Date *

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