Dental Anesthesia Release Form

Dental Anesthesia Release Form
Name*

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Patient Name*
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For the safety and comfort of our patients, and for the peace of mind of our clients, we have a minimum set of requirements before, during, and after anesthesia. We offer additional care above and beyond our minimum standards for those cases requiring more, as outlined below. All of the costs of this care will be fully outlined in the treatment plan before services are rendered. While we attempt to be accurate it does not include the cost of unforeseen circumstances and all efforts will be made to contact you if this occurs.

For safety and comfort, we require the following:

-          A current examination no more than one year prior to the procedure

-          Blood test to determine underlying problems for all patients

-          IV fluids for stabilization under anesthesia and support during recovery

-          Medication will be given before and after the procedure that lessens the perception of pain

-          Treatment on sight of fleas, flea dirt or ticks, at owner’s expense

-          Pre-Surgical EKG to further decrease the risk associated with anesthesia
My pet is undergoing a dental cleaning today, and if during anesthesia the doctor determines that one or more teeth need to be extracted, please note that the cost of extractions can range from $20 to $125 (per tooth) dependent on the number of roots, complications during extraction and time involved. Many extractions can not be identified without the use of radiographs(x-rays) to see below the gum line. *
I am the owner or authorized agent and hereby authorize County Line Veterinary Clinic (doctor and staff) to administer treatment and anesthesia as are determined to be necessary by the attending veterinarian. Further, I understand why such diagnostic, medical and/or surgical procedures are being performed as well as their advantages and possible complications, and I do hereby release Dr. Fowler or the attending veterinarian and staff from any and all liability arising from these procedures for said animal. I am aware that veterinary service and/or observation is not provided overnight.
If your pet becomes ill, we will call the emergency phone number you provide. If no one can be reached and medical attention is required, do you authorize whatever services the doctor deems necessary?*
If you would like to treat up to a different amount than $500, please notate the amount below.
Initials*
Hospitalization/Overnight Care

I understand County Line Veterinary Clinic (CLVC) is not a 24 hour facility and does not have staff available to provide care outside of normal staffing hours. It is the recommendation of CLVC that all pets needing afterhours care or hospitalization be transferred to an afterhours care facility.

I agree to pay for all services at the time that they are rendered.*

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We will call or text to notify you when your pet’s dental is completed. Please check if you would like a call or a text*
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