Anesthesia Dental Consent
Pet's Name
First & Last Name
Date
-
Month
-
Day
Year
Date
Species
Age
Sex
Weight
Best Phone Number to reach you:
Please enter a valid phone number.
Format: (000) 000-0000.
Owner Full Name
First Name
Last Name
When did your pet last eat?
Is your pet sick?" to "Is your pet coughing, sneezing, vomiting or having diarrhea? If yes, please explain
Any additions you would like during todays procedure? Please select.
Microchip Placement ($55)
Nail Trim (Free)
Anal Glad Expression ($51)
What medications is your pet receiving at home? Last dose (amount given) and time given? (List ALL medications)
Has your pet been scratching, itching or scooting?
I authorize the doctor to perform any and all extractions that are medically necessary, regardless of cost for my pet's health and I agree to pay any and all costs associated with this service.
*
I authorize an additional amount in case my pet needs extractions. Please select the amount you are willing to authorize up to.
$550
$900
$1300
I would like the DVM to call me with an estimate. I understand that if the DVM cannot reach me, or has not heard back from me within 10 minutes of a call regarding the need for extractions, my pet will be woken up and will have to be re-anesthetized on the same/or later day/date at an additional coast.
I acknowledge that there are certain risks to anesthesia, that could involve serious bodily injury or even death to my pet and that these risks are present in any procedure that requires a general or intravenous anesthetic. I certify that I am the legal owner/duly authorized agent for the owner of the animal described above, and do herby authorize Murphy Avenue Pet Clinic to provide care and perform treatment up-to and including diagnostic bloodwork, x-rays, vaccines, medications and administration of medical procedures they consider reasonable and necessary for my animal’s health, safety and comfort. I understand that with any medical procedure there are always risks involved, including death, and that no warranty or guarantee is being made as to the results or cure. I understand additional charges will accrue if my animal is not picked up before the hospital closes on the day he or she is ready to be released from the hospital. I understand payment in full is expected at the time of pick up and I assume full responsibility for all fees associated with the veterinary services provided.
I understand every effort will be made to contact me and if I am unreachable my pet’s services may not be performed/completed in their entirety which could result in repeat visits and additional fees. Please initial below.
Owner Type Name
In the case of an emergency, please notate if you would like us to initiate life saving procedures for your pet, or decline. If CPR is selected, know that there will be a $500 minimum to start services, however we will call you and alert you right away. Please select one.
DNR
CPR
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