Dental Sedation/Anesthesia Surgical Release Form
Oxford Animal Hospital
Name
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First Name
Last Name
Pet's Name
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Pet
If you have a change to address, please enter here:
Where can you be reached today?
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Please enter a valid phone number.
Format: (000) 000-0000.
Would you like to receive a text message prior to your pet heading into surgery?
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Yes
No
Is your pet currently taking any medications? List Name, Dose, Frequency. Please do not put "See Records", this alleviates any potential confusion.
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If yes, please list medications here
I would like my pet to receive a microchip today.
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Yes. I understand additional fees apply.
No thank you.
We recommend lab analysis by histopathology (biopsy) of all surgically excised tissue. I understand the doctor's recommendation and elect to:
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Accept. I understand additional fees apply.
Decline
Does not apply
Sanos Dental Sealant prevents plaque and tarter from attaching to the surface of the teeth. We will administer this today after the dental cleaning and it will last 6 months. I understand the doctor's recommendation regarding administering the Sanos Dental Sealant. *For dogs and cats*
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Accept. I understand additional fees apply.
Decline
Does not apply
Oxford Animal Hospital will provide a Complimentary Nail Trim to all patients under anesthesia. Would you like to upgrade this service to a Nail Grind, there will be an additional cost for this service at a discounted rate.
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Yes
No thank you
Any procedure requiring general anesthesia poses certain risks and serious complications; even death may result. By signing below you acknowledge that you understand these risks and that your decision regarding our Doctor’s recommendations and/or instructions have been reviewed with you for your pet’s Treatment Plan. Our hospital has high standards concerning the care and treatment of your pet and we will make every effort to contact you if further treatment is deemed necessary. The Treatment / Surgery Plan for your pet is based on current findings. If additional procedures or tests are medically indicated after the procedure begins (ie, surgical findings or the unlikely incident of anesthetic reaction) we should:
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Do whatever is necessary including extractions and/or oral surgery and have the nurse call me once my pet is in recovery.
If possible, call me first, but do not withhold medical care if unable to contact me while my pet is under anesthesia.
Do only what is on the Treatment Plan and/or has been discussed. No extractions or other dental care except cleaning.
Do you have any other medical concerns with your pet that we should address prior to his/her procedure?
I acknowledge that I will not feed my pet after 10pm the night prior to anesthesia.
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Yes
I certify that I am the owner/agent of the animal above and I do consent and authorize Oxford Animal Hospital and its doctors and staff, to hospitalize my pet, administer medications, tests, surgical procedures, anesthetics, or treatments that the Doctors deem necessary for the health, safety or well being of the above animal while it is under their care and supervision. If my pet should injure itself in an escape attempt, refuse food, soil itself, become ill, or die while in the hospital, I will hold Oxford Animal Hospital and its staff free of any responsibility and/or liability in the absence of gross negligence. I further realize that I am responsible for payment for the procedure(s) and treatment in full at the time the animal is discharged. If I neglect to pick up the animal within five (5) days of written notice that it is ready for release and mailed to the above address, you may assume that the pet is abandoned. You are then authorized to dispose of it as you see fit. Abandonment does not release me of my obligation for the charges. I further agree that in the case of non-payment, a finance charge of 1.5% per month (18% per annum) will be charged. I will pay any collection fees in full. For the protection of your pet and others at our facility, we will treat your pet at your expense for fleas, ticks, or internal parasites if found.
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I agree
Signature
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Today's Date
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Month
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Day
Year
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