Dental Surgery and Anesthesia Consent Form

Client Name*

First NameLast Name

Email*

example@example.com

Date*

Patient Name*

Species*

Breed*

Color*

Sex*

MaleFemale

Approximate age of pet

Weight*

Phone Number*

Please enter a valid phone number.

Today's Phone Number *

(This number needs to be reliable to reach you while your pet is under anesthesia.)

Does your pet have allergies?*

YesNo

Allergies

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

1. Perform what is medically necessary.2. Please call the phone number above

Is your pet on any medications?*

YesNo

Please list medications your pet is on.

Is your pet allergic to any medications?*

YesNo

Please list medications your pet is allergic to

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

YesNo

If yes, please list below

As the owner or agent of the animal listed above, I hereby give my consent to Akin Hills Pet Hospital to perform the dental cleaning and polishing.

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.

The following options are optional. They will be performed (and you will be charged) unless you refuse them and initial below.

Pre-Anesthetic Blood Testing*

YesNoAlready Performed

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

YesNoOther

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

YesNo

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.)

YesNo

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

I’m aware of this requirement and have proof of vaccination or I am giving Akin Hills Pet Hospital authorization to give the vaccination.

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

Yes

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.*

Yes, I do understand.

Signature*