Caledon Vet - Oral Surgery Consent Form

Pets Name*

Pets Age*

Pets Breed*

Pets Color*

Pets Sex*

Does your pet have any underlying medical issues?*

YesNo

If yes, please detail below.*

Has your pet shown any signs of illness within the last 2 weeks? (For example: lethargy, vomiting, diarrhea, seizure, muscle weakness, difficulty breathing, etc.)*

YesNo

If yes, please explain.*

Is your pet currently taking any medications, vitamins, or supplements?*

YesNo

If yes, please list the medications including dose and frequency*

Does your pet have any food or medication allergies?*

YesNo

If yes, please list here.*

Do you feed your pet raw food (meat)?*

YesNo

If yes, please note that we strongly recommend cooking/searing your pets raw food for 10-14 days aftersurgery, until their surgical incisions sites are healed to reside the chances of infection caused by bacterialcontamination.*

I understand

Our goal is always 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 invoice to vary from the original estimate. Please read and choose one of the following statements regarding your pets oral surgery.*

Please perform any extractions/procedures that the Veterinarian deems necessary without contacting me first, I understand there may be additional costs above the estimate that was provided to me.Please call me before performing any extractions/procedures above those indicated in my estimate. If I am not available within 10 minutes of your call, I give permission to perform any extractions/procedures that the Veterinarian deems necessary.Please call before performing any extractions/procedures above those indicated in my estimate. If you are unable to reach me, I understand that no additional procedures will be performed without my authorization, even if deemed necessary.

Oral Surgery Date*

Date

Owner Name*

First NameLast Name

Phone Number where you can be reached on the day of surgery*

E-Mail Address

example@example.com

Please check mark each item below to signify that you have read and understand the following*

I, the undersigned, being 18 years of age or older, and as the authorized owner or representative, understand the general nature and benefits associated with the procedure/treatment. I hereby authorize the personnel of Caledon Mountain Veterinary Hospital to carry out all procedures described herein, or any other procedures required by the condition of my pet.I understand the associated risks, complications, or side affects with the scheduled procedure or treatment. I understand that there is some risk involved with any medication given, any procedure performed, and with general anesthesia. In particular, I have been advised that there is a risk of death every time an anesthetic and/or surgery is performed.I understand the Veterinarians are diligent in assessing each patient's current health status to create an appropriate treatment plan, but that there may be adverse events that are not predictable even after assessing a patient's current health status. I understand that all procedures will be performed to the best of the abilities of the hospital staff but that there can be no guarantee as to my pets condition, reaction to, or the outcome of any medication given or procedure/treatment undertaken.I understand that auxiliary staff (Veterinary Assistants, Registered Veterinary Technicians) and other Veterinarians may provide some of the treatment and care for my petI understand that Caledon Mountain Veterinary Hospital does not have staffing coverage available on site to monitor patients after regular office hours.I have been (or will be) provided with an estimate and I understand that I am responsible for all charges incurred for the care of my pet and that payment is due at the time services are rendered.

In case of unforeseen emergency*

I give permission to proceed with life sustaining procedures for my pet, and understand I am responsible for any additional cost associated with these procedures(starting at approx. $220).I DO NOT give my permission to proceed with life sustaining procedures for my pet.

We love to share pictures of our adorable patients!
If we were to take a picture of your pet we would like your permission to use it in our social media content, promotional materials and/or publicity efforts. These photographs may be used in publications, print ads, direct-mail pieces, electronic media (e.g. video, Internet, Web site) or other forms of promotion in perpetuity without remuneration or further consent. Your pet’s name may be shared but your identifying information would not be.
No, I DO NOT give permission for my pets photographs to be taken. Yes, I give my permission for my pets photograph to be taken and used for the purposes indicated above.

Signature*

Today's Date*

Date