Dallas Veterinary Clinic - Surgical OR Dental Consent Form

1
Date* This field is required.
Date
Year
Month
Day
2
Pet Information* This field is required.
Pet Name
Please Select
Please Select
Canine
Feline
Species
Age/Date of Birth
Please Select
Please Select
Male
Neutered Male
Female
Spayed Female
Sex
3
I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. My signature below certifies that I am over eighteen years of age.* This field is required.
I have read and understand
4
I affirm pet hasn't had anything to eat or drink since midnight the night prior to the procedure* This field is required.
Yes
No
5
I have been informed that there are certain risks and complications associated with sedation, anesthesia, and/or any operation/procedure and that the risks/complications have been explained to me. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before the procedure is initiated. I authorize the use of appropriate anesthesia and pain relief medication as needed before, during or after the procedure. I have been informed that there are risks associated with the use of any medication and/or surgery and I authorize the staff of this hospital to perform the procedure(s) listed above, as well as those deemed necessary to treat life-threatening emergencies. I GIVE FULL CONSENT IN ADVANCE FOR ANY MEDICALLY NECESSARY TOOTH EXTRACTIONS DURING ANY DENTAL CLEANING. As with all anesthetic, treatment, and/or surgical procedures, I understand there are risks inherent in these services. In the event that my pet should require emergency life-saving efforts while being hospitalized today, I give consent for treatments to be initiated until I can be contacted further and notified of my pet's status. By consenting to this service, I also acknowledge that fees will apply. Life-saving efforts will be continued to be performed at the doctor’s discretion until my pet is stable and I can be contacted to consent to further treatment plan.* This field is required.
I have read and understand
6
Do you want us to TRIM NAILS while under sedation? ($23)* This field is required.
Yes
No
7
Do you want us to MICROCHIP your pet while under sedation? ($79.99 + tax)* This field is required.
Yes
No
8
If your pet is here for DENTISTRY, do you want us to apply Oravet Sealant to the teeth after cleaning? ($29)* This field is required.Oravet Barrier Sealant binds electrostatically to tooth enamel, creating an invisible barrier that helps prevent plaque-forming bacteria from attaching. The patented polymer is biologically inert and has been clinically proven to significantly reduce the formation of plaque and calculus in dogs.
Yes
No
9
Would you like Oravet Plaque Prevention Gel Take-Home Kit ($49)* This field is required.Gel is applied to the teeth using the included applicator supplied and takes less than a minute. This in-home application maintains the plaque and calculus barrier created by the sealant applied in the clinic. OraVet Plaque Prevention Gel is odorless, tasteless, invisible. Can be applied weekly or monthly to significantly reduce plaque & calcium formation.
Yes
No
10
Please type all procedure(s) and/or treatments to be performed* This field is required.
11
Please describe any additional services you would like for your pet today not already listed here
12
As with any procedure requiring general and/or local anesthesia, there are certain risks that serious complications or even death may result. To minimize the risk of such occurrences, for the safety of your pet, our doctors STRONGLY recommend pre-anesthetic bloodwork in order to assure proper organ function, clotting ability, detect anemia or infection.* This field is required.Please select ONE of the following: (REQUIRED to CHOOSE ONE):
Same-day bloodwork: CBC, chem15, electrolytes only ($162 - $177)
I brought my pet to DVC no more than 48 hrs prior for full blood panel (CBC, chem17, lytes + thyroid) (does not include specialty add-ons such as pancreatitis or cardio). Labs sent to reference lab. ($154)
I understand the risks, that my pet could have underlying/unknown medical condition/infection and I DECLINE pre-anesthetic bloodwork against the advice of my veterinarian
13
The complete blood count (CBC) is a much more sensitive indicator of disease than physical exam. White blood cells (WBCs) and platelets can change within hours due to acute infectious diseases. Abnormal glucose levels can increase anesthetic risk and differ markedly between fasted vs non-fasted, breeds, age & sick vs healthy patients. Evaluating electrolytes, hematocrit and total protein in fasted patients is essential for anesthesia monitoring, minimizing the risk of arrhythmias, hypotension, & facilitating patient recovery.
14
The nature of these operations or procedures has been explained to me and I understand what will be done. I am aware that the practice of veterinary medicine is not an exact science and, thus, no guarantees have been made regarding the outcome of this treatment(s)/procedure(s). I have been encouraged and given the opportunity to discuss any questions I may have regarding my pet's medical care and my questions have been answered to my satisfaction. I accept that my financial obligations remain and I agree to pay for all services related to these procedures/treatments regardless of the outcome. I have read and understand the nature of the treatments and procedures being done today, I understand this authorization and hereby accept and agree to the terms of the consent for treatment. I agree that, in being fully responsible for my pet, I will ensure that either I or someone I authorize will pick up my pet during business hours. If, in the event of an emergency or I am unable to get to DVC to pick up my pet before closing I agree that my pet will be boarded at DVC at my expense until I or my authorized representative can pick up my pet.* This field is required.
I have read and understand
15
DVC IS OPEN 7:30-5:30 M-F, 8-12 SAT. PLEASE ENSURE YOU ARRANGE PICKUP FOR YOUR PET BEFORE 5:30 as we do not have staff available after-hours. The DVM will advise of time after which pet will be ready for pick up-if you need clarification please ask. Pick up is typically between 4:00-5:00, and please be prepared to be here for at least 10 minutes for discharge of the patient. If patient is not picked up by closing time, the pet will stay overnight at $100 per night OR will be transferred to an Emergency clinic for hospitalization at clients expense. DVC does NOT have staff in the clinic after business hours.
16
Please TYPE in the best phone number to reach you today* This field is required.
17
DNR Release: If your pet were to stop breathing or suffer cardiac arrest while under our care, we need to know your wishes in advance. This difficult decision is important and involves two medically standard choices.* This field is required.
Standard CPR involving medications and chest massage
DO NOT RESUSCITATE (DNR), no life saving measures requested
18
Owner's Information* This field is required.
Owner's First Name
Owner's Last Name
Email
19
I understand that DVC requires payment at the time services are rendered and does not offer payment plans or deferred billing of any kind. I take full responsibility for the pet(s) I'm presenting to DVC (either in person or virtually via phone/video consult) and agree to be fully financially responsible for paying in full TODAY. I understand and fully acknowledge that if I have a specific budget or any financial concerns or limitations I can ask for a treatment plan which will be provided before any treatments are performed, except for the office visit/exam/consultation, which I agreed to pay in full by coming here (or calling) and presenting my pet(s) or discussing my pet(s) with the veterinarian today. I understand that I can decline some services/goods, (even if against the advice of the veterinarian), if I am unable to pay for everything recommended and I promise to clearly decline items (EXCEPT the office visit/consultation/exam-which cannot be declined) if financially necessary BEFORE they are performed.* This field is required.
I have read and understand
20
I understand DVC does not offer financing or payment plans and promise to take full responsibility for and pay in full for ALL costs incurred in treatment of my pet(s) AT TIME OF SERVICE.* This field is required.
I have read and understand
21
Signature* This field is required.
Clear
Should be Empty: