Dental Anesthesia Consent Form

Dental Anesthesia Consent

Please read the information, then fill out applicable questions about your pet.
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:
Please attempt to contact me at the number provided. If I am unable to be reached, please proceed as the veterinarian feels is appropriate; I understand that I will be responsible for whatever fees are associated.Please attempt to contact me at the number listed. If I am unable to be reached, DO NOT provide any additional services that were not originally estimated.
Which method of contact do you prefer today:*

Phone callTextEmail
Is your pet experiencing any of the following:*

CoughingSneezingVomitingDiarrheaNone of the above (no coughing, sneezing, vomiting, or diarrhea)Other
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.

Ear CleaningNail TrimAnal Gland ExpressionSanitary ClipMicrochipOther
Has your pet gone 8-10 hours without food (fasted)?

YesNo

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)*

	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?

NoYesOther
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.*

Yes, I received an estimate for the cost of services that I agree toNo, I did not receive an estimate
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. *

Clear
Client/Owner Name*

First NameLast Name
Should be Empty: