Dental Anesthesia Consent Form

Today's Date

MonthDayYear

Name of Pet

Anesthetic Procedure(s) to be Performed

Primary Phone Number

Area CodePhone Number

Additional Phone Number (If I cannot be reached at the primary phone number)

Area CodePhone Number

Email

example@example.com

If your pet requires multiple extractions, the veterinarian may need to stage my pet's procedures and perform the extractions at a later visit. Common reasons that this would be necessary include length of time under anesthesia, estimated pain involved in the procedure, difficulty of the extraction, ect.

Understanding that during the dental cleaning and examination abnormalities may be found that were previously undetectable. Your pet may need to have teeth extracted. If this can be performed today, one of our surgical team members will attempt to contact you. In the event that you are unable to be reached, which of the following options would you prefer:

Which method of contact do you prefer today:

Is your pet experiencing any of the following:

I would like these additional procedures to be performed during my pet's visit. I understand these procedures may incur charges beyond what I was estimated for the original procedure.

Has your pet gone 8-10 hours without food (fasted)?

Please list the medications you give your pet, and the last time they were given. (if your pet is not on any medications/supplements please type "none" in the first box)

Rows	Name and Dose	Time Last Given	Date Last Given
Medication
Medication
Medication
Medication

Does your pet have any food or drug allergies that you're aware of?

Other

Do you have any additional concerns or questions for the anesthesia team?

I was provided an estimate for services today and understand that payment is due upon discharge from the hospital.

In the event that your pet is deemed unstable on presentation to Strawbridge Animal Care or becomes unstable while in the care of your veterinarian, we ask you to define your wishes for stabilization treatments, care, and/or diagnostics. Your pet's medical care team will make every attempt to contact you prior to these procedures being performed, but in some instances it may be in your pet's best interest to have these procedures and/or diagnostics performed immediately. These procedures and/or diagnostics may include an urgent physical exam, an intravenous catheter, intravenous fluid therapy, oxygen support, blood work, and/or pain medications.

I elect and authorize stabilization procedures and/or diagnostics for my pet. I understand that depending on my pet's condition, these procedures may or may not improve my pet's prognosis; however they do improve the ability of my pet's medical care team to respond to changing conditions more rapidly and effectively. Critical care stabilization procedures and/or diagnostics can incur costs between $350-$450.

If your pet goes into acute cardiorespiratory arrest, we ask you to define your wishes for administration of CPR and life saving measures. CPR is the resuscitation of an animal that has stopped breathing and /or whose heart has stopped beating. CPR is successful at returning normal heart, lung and brain function in, unfortunately, the minority of patients who have arrested. Animals that have survived cardiopulmonary arrest and have been successfully resuscitated (CPR) are critical and unstable. The likelihood of re-arrest is high following resuscitation and there is only about 15% short-term and

Signature

I am the owner or the agent for the owner of the animal described and have the authority to execute this consent. I hereby consent and authorize the veterinarian(s) of Strawbridge Animal Care to perform the procedure listed . There is always risk associated with surgery and anesthesia. Some patients will be a higher anesthetic risk compared to others due to known or unknown physical or metabolic abnormalities. My pet’s anesthetic risk based on what we know about my pet has been determined by my veterinarian and explained to me. I understand that during the performance of the foregoing procedures or operations, unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure operation or different procedure or operation as those set forth. Therefore, I hereby consent and authorize the performance of such procedures and operations as are necessary and desirable in the exercise of the veterinarian's professional judgement. I understand that every effort will be made to contact me and advise me of any unforeseen change in the treatment plan. I have been advised of the services that Strawbridge Animal Care has the capabilities of performing as it pertains to the procedure(s) that I am authorizing. I have been advised that no staff is available on the hospital premises except during normal hospital operating hours. By signing below with my finger or mouse, I attest that I understand the procedure to be performed on my pet and have no further questions at this time. I will be available at the phone number(s) listed below at all times during the day of the procedure.

Client/Owner Name

First NameLast Name

Dental Anesthesia Consent

Critical Care Stabilization Authorization

Resuscitation Orders