Anesthesia Dental Consent

1152 Stonecrest Boulevard

Tega Cay, SC 29708

(803) 547-8387

www.baxtervet.com

Anesthesia/Surgery Consent Form

Client Name*

Patient Name*

As the owner or agent of the above pet, I hereby give my consent to Baxter Veterinary Clinic to perform the following procedure(s) and understand that anesthesia or sedation may be necessary.

Procedure(s) Requested*

When did your pet eat last?*

I do / do not understand that during the performance of this procedure(s), unforeseen conditions may be revealed that necessitate a change of procedure or additional procedures. I expect the staff at Baxter Veterinary Clinic to use reasonable care and judgement in performing the procedure(s). The nature of the procedure(s) and the risks have been explained to me, and I realize results cannot be guaranteed. I am also aware that unforeseen events resulting from the procedure(s) will not relieve me from any financial obligation incurred regarding my pet.*

I Do Authorize Performance for Unforeseen ConditionsI Do NOT Authorize Performance for Unforeseen Conditions

Current Medication(s):

Refills Needed:

I do / do not authorize any necessary extractions today. The cost of tooth extraction ranges from $15-$90 depending on the procedure required to remove the tooth. If this has not already been discussed with you, please let us know and the doctor can discuss this with you.

I Do Authorize Any Necessary ExtractionsI Do NOT Authorize Any Necessary Extractions

I do / do not authorize singe / full mouth dental radiographs today.*

I Do Authorize Full Mouth RadiographsI Do Authorize a Single RadiographI Do NOT Authorize

I do / do not authorize CPR or other life saving procedures in the event of an emergency.*

I Do AuthorizeI Do NOT Authorize

I would / would not like my pet microchipped today with a HomeAgain microchip. (The enrollment is paid by the clinic.)*

I Do AuthorizeI Do NOT Authorize

I would / would not like my pet to receive therapeutic laser treatment to assist healing following the procedure.*

I Do AuthorizeI Do NOT Authorize

As discussed, I understand and consent to have the services performed today.*

My signature above verifies that I am at least 18 years of age and am financially responsible for this pet. With this signature, I agree to terms and services discussed on this consent form.)

Best contact name and number:

You will be notified by text message when your pet's care is complete.