Veterinary Anesthesia Consent Form

Owner Name*

First NameLast Name

Owner Email*

example@example.com (NA if not applicable)

Owner Phone Number*

Please enter a valid phone number.

Owner Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pet Name

Pet Species*

Pet Age*

Pet Weight*

Date and time of last meal:*

List of current medications:*

Procedure(s) to be performed:*

As with any procedure requiring general and/or local anesthesia, there are certain risks and serious complications or even death may result. To minimize the risk of such occurrences, we strongly recommend baseline bloodwork be performed in order to assure proper organ function, clotting ability, detect anemia or infection, and a general baseline for future reference. Please indicate if you consent to pre-anesthetic bloodwork below:*

Yes (Chem10 and CBC - $160)No

As the owner of the above pet, I certify that I am over the age of 18; and I authorize the staff of this hospital to perform the procedure listed above, including the removal of any teeth that the veterinarian deems medically necessary to extract as well as the appropriate pain management medication(s).

Dental Extraction Costs (per extraction):

One Root: $18.15
Two Root: $ 48.40
Three Root: $72.60
Canine Tooth: $121.00
Dental Nerve Block: $29.00

I also authorize any treatment deemed necessary to treat life-threatening emergencies. As with all anesthetic, treatment, and/or surgical procedures, I understand there are risks inherent in these services. Further, I understand that I am financially responsible for all costs incurred during this surgery, treatment, and hospitalization. These costs may also include minimal measures including drugs and assisted breathing.

While I accept that all procedures will be performed to the best of the abilities of the staff at this facility, I understand that veterinary medicine is not an exact science and that no guarantees have been made regarding the outcome of this/these procedures. I have read and understand the nature of the above procedures and accept the specific terms and conditions set forth herein.

Should unexpected life-saving emergency care be required I would like the hospital staff to attempt the following life saving measures (select one):*

Closed Chest Resuscitation (CPR)Do not attempt resuscitation

Signature*

By signing this form I acknowledge that I am responsible for payment in full for the above procedures and treatments at the time my pet is discharged.

Dental Anesthesia Consent Form