Spay and Neuter Consent- Feline

Dental Consent Form

Please fill out this form in entirety to ensure we can provide your pet with the best possible care.
Your Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Pet's Name*
Type of pet*

CatDog
Possible Surgical Complications
General Surgery and Dentistry

- Anesthetic complications that could result in death
- Hemorrhage
- Dehiscence (breakdown of incision)
- Infections
- Necrosis (death) of skin
- Reaction to suture
- Delayed wound healing
- Fracture of jaw
- Oronasal Fistula
- Retained roots

Spay procedures (in addition to those listed under General Surgery)

- Hernias
- Bleeding during or after surgery internally, from the incision or from the vulva that can result in death
- Ovarian Remnant
- Urinary incontinence (occurs later in life)
- Urethral Trauma

Castration Procedure (in addition to those listed under General Surgery)

- Scrotal swelling or hematoma

- Hernias

These complications, although rare, are inherent risks of performing general anesthesia and surgery. This is not an all-inclusive list, and other complications are possible. Reading and following discharge instructions is the owner’s responsibility and is critical to healing and full recovery.

The treatment of these complications will be at the expense of the owner.
Pet History
Is your pet up to date on their vaccinations?*

YesNo, Being that we are a full-service clinic, we regularly treat animals with contagious diseases. We recommend your pet be fully vaccinated.
Canine: Please check the appropriate box if you would like us to update their vaccinations today:

Rabies $31.00DH(L)PP (Distemper/Parvo) $47.50Bordatella (Kennel Cought) $44.50
Feline: Please check the appropriate box if you would like us to update their vaccinations today:

Rabies $31.00FVRCP (Distemper) $47.50FeLV (Leukemia)*: $51.50 * Recommend testing before vaccinating
Is your pet allergic to any drugs?*

YesNo
Has your pet had any illness or injury in the past 30 days?*

YesNo
Any history of seizures and/or previous anesthetic problems?*

YesNo
Please provide details if you answered yes to any of the above history questions
Current Medications (including Supplements)? If yes, please indicate time of last dose.
Extraction Consent/Waiver
Many pets require sedation before a thorough oral examination can be completed. The condition of each tooth must be evaluated before a decision is made as to the best course of treatment. Although no one likes surprises, it sometimes is impossible for us to give you an accurate estimate before we start your pet’s dental cleaning. In an effort to satisfy your desires, please initial the appropriate option below:
Please perform whatever procedures & extractions are required at this time.Please do nothing more than the requested dental cleaning procedure at this time. No extractions are authorized regardless of the health of the tooth.Please call me after the exam with an estimate if any additional procedures are needed. **Please note that if we are unable to reach you the morning of your pet’s procedure, we will proceed with extractions as deemed necessary and at owner’s expense. **
OPTIONAL SERVICES WITH SURGERY (ALL COSTS ARE ADDITIONAL)
There are many optional preventive health care services that can be provided for your pet during its surgery visit. We suggest the following procedures be done at the same time we are performing other necessary services for your pet. By allowing us to perform these elective procedures now, you will be providing optimum health care for your pet, while at the same time possibly saving you future additional expenses and heartache.
ORAVET TARTAR PREVENTION SYSTEM: Sealant cost= $24.60 (sm dogs); $49.20 (large dogs) A barrier sealant is applied after scaling and polishing. This reduces the amount of bacteria that adhere to the gum line, thus decreasing the amount of tartar buildup. Home care products to prolong the tartar prevention include: 1)prevention gel that is applied ONE time weekly with a swab to the teeth 2) Oravet Dental chews that are given once daily.

Yes, please apply the Oravet SealantNo, I am declining Oravet Sealant
Please select the following product for use at home

Oravet Treats- $46.50 or less for 30 day supplyOravet Prevention Gel- applied weekly - $37.50 for 2 months supply
PRE SURGICAL LABORATORY SCREENING: Cost = $72.50 This blood analysis provides us with information on the health status of your pet before surgery. Among other things, a pre anesthetic panel analyzes liver and kidney health. This testing allows us to better tailor our anesthesia protocol to their individual needs. This service is highly recommended for any pet over 5 years old.*

Yes, please check my pets blood prior to anesthesia.No, I would like to decline blood work at this time.
INTRAVENOUS CATHETER AND FLUIDS: Cost = $104.00 While your pet is under anesthesia, we do our best to safeguard your pet’s health. Your pet can be further protected by the administration of intravenous fluids to maintain your pet’s blood pressure during surgery, counteract any blood loss, and speed their recovery from anesthesia. If an emergency were to arise, an intravenous catheter will help us greatly in our efforts to save your pet. This service is highly recommended for any pet over five (5) years of age.*

Yes, I would like intravenous fluids for my pet.No, I am declining intravenous fluids for my pet at this time.
EAR CLEANING: Varies, starts at $36.00; Treatment = Varies If we find that your pet has ear mites or an ear infection, we can easily clean and treat your pet’s ears while it is under anesthesia, which is easier on the pet than if they are awake. Medications to treat your pet’s ears will be an additional charge depending upon the condition.*

Yes, please check my pet's ear and treat as neededNo, I am declining any ear treatments
ANAL GLAND EXPRESSION: $37.00 Dogs and cats have glands around their anal region that provide marking scent for their feces. Occasionally these glands will become full and possibly infected,leading to pain and discomfort. While your pet is under anesthesia for its dental cleaning, we can check their anal glands and express them if required.*

Yes, Please express my pet's anal grands and treat as neededNo, I am declining anal gland expression
MICROCHIP IDENTIFICATION Cost: $68.50 This microchip will assign your pet a unique 10-digit code that can be used to identify or prove ownership of your pet. If your pet were ever to become lost, a microchip would help speed its return to your family. This is not a tracking device.*

Yes, please place a microchip in my petNo, I am declining a microchip placement
WART/SKIN GROWTH REMOVAL: Price Varies; Base cost $102.35 If there are any skin growths you would like removed, we may be able to do so at the time of a dental cleaning. The doctor will examine your pet before proceeding with the dental. We will call with an estimate if the cost is over the base value.*

Yes, please remove any warts/skin growthsNo, I am declining any mass removals
DEWORMING: Cost up to $60 (based on weight) Recommended for pets over 4 months of age. Treatment for internal parasites including tapeworms*

Yes, please deworm my pet for internal parasites including tapewormsNo, I am declining deworming of my pet
RESUSCITATION CONSENT AT NO ADDITIONAL FEE

While all efforts will be made to assure the health and safety of your pet while under anesthesia,there are inherent risks with any anesthetic and surgical procedure. Occasionally, complications may arise during which we may need to resuscitate your pet. In order to better fulfill your wishes, we ask that you take a moment to consider the extents to which you wish us to go in order to save your pet.
Resuscitation Consent

Code 1: Do Not Resuscitate (DNR)**Code 2: External CPR (cardio-pulmonary resuscitation) Only
**IF CODE 1(DNR) IS SELECTED, PLEASE BE AWARE THE DOCTOR WILL NOT PERFORM ANY FORM OF CPR IF ANY COMPLICATIONS ARISE DURING THE SURGICAL PROCEDURE
I acknowledge my choice regarding resuscitation choice for my pet as noted above.
Initial
Surgery Release/Consent

By signing below, I acknowledge that I have read the POSSIBLE SURGICAL COMPLICATIONS form, and agree to release Sagehills Veterinary Services and their doctors and staff from any and all liabilities and legal claims that may occur as a result of surgery and/or complications that may develop. Any disputes shall be settled by mediation in Adams County, Washington.
Date

MonthDayYear
Date
Signature*

Clear
Phone number we can reach you at while your pet is in our clinic?
Any pet that has fleas when admitted to the hospital will be treated for fleas at the owner’s expense
Should be Empty:

Dental Consent Form

Possible Surgical Complications

Pet History

Extraction Consent/Waiver

OPTIONAL SERVICES WITH SURGERY (ALL COSTS ARE ADDITIONAL)

RESUSCITATION CONSENT AT NO ADDITIONAL FEE

Surgery Release/Consent