Dental Surgery and Anesthesia Consent Form

Client Name

First NameLast Name

Email

example@example.com

Date

Patient Name

Species

Breed

Color

Sex

Approximate age of pet

Weight

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Today's Phone Number

(This number needs to be reliable to reach you while your pet is under anesthesia.)Format: (000) 000-0000.

Does your pet have allergies?

Allergies

If Extractions are needed, please choose how you want us to proceed:

Is your pet on any medications?

Please list medications your pet is on.

Is your pet allergic to any medications?

Please list medications your pet is allergic to

Is your pet on any supplements (joint supplements, CBD, etc.)?

If yes, please list below

If your pet is to be anesthetized, be assured that advances in anesthesia and surgery have been made for routine procedures relatively safe with a low rate of complications. Nonetheless, occasionally problems can arise due to pre-existing conditions that may not be noticed during the pre-anesthetic examinations. To avoid these problems, we recommend all pets be screened prior to anesthesia by the following laboratory tests.

1. Pre-anesthetic Blood Screening: organ function tests, packed red blood cell & total plasma protein measurements.

2. IV catheter and Fluids: aids in adequate blood pressure and gives immediate access to the vein if an emergency arises.

Bloodwork is required if over 1 year of age OR if bloodwork has not been done within the last 3 months. Heartworm tests are required if over 1 year of age and has not been done in the last year.

Pre-Anesthetic Blood Testing

Heartworm Test (dogs, if not up to date or on heartworm preventative)

Feline Leukemia/FIV test (If your cat is not up to date on vaccines or an outdoor cat)

Do you consent to a 3-5 minute ultrasound on your pet? (We are currently learning a new technology and trying to become more knowledgeable and comfortable looking at normal anatomy on ultrasound. This would be at no extra charge to you and would only be done if your pet is stable under anesthesia.)

Rabies Vaccine: (a current rabies vaccine is required for all pets at our clinic).

We agree to fast our pet overnight, with no food after 10 PM (can offer water)

I understand that during the performance of this procedure, unforeseen conditions may be revealed that can delay or change the procedure set forth above. I expect Akin Hills Pet Hospital to use reasonable care and judgment in performing the procedure. The nature of the procedure and the risks involved, including death, has been explained to me and I realize results cannot be guaranteed therefore, I will not hold Akin Hills Pet Hospital liable if something happens to my pet. I am also aware that unforeseen events resulting from the procedure will not relieve me from any obligation to all reasonable costs incurred regarding my animal.

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