Dental & Surgery Combo Check-in Form

West Coast Animal Hospital

5269 Linda Vista Rd
San Diego, CA 92110
United States
(619) 431-1423
info@westcoast.vet

Consent for Sedation or Anesthesia

AUTHORIZATION

I verify I am the Owner (or Authorized agent for the owner, at least 18 years or older) of the above named animal and authorize the above procedure to be performed. I authorize the use of sedation, anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure(s) as directed by the veterinarian. I have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any sedation or anesthesia episode, even in apparently healthy animals and have discussed my concerns with the veterinarian. While I accept that all procedures will be performed to the best of the abilities of the veterinarians and staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I understand that any estimates provided for such procedures are for non-complicated procedures and that any unforeseen complications may result in additional costs. I understand that it may be necessary to provide medical and/or surgical intervention which were not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. I accept responsibility for any result in additional charges. I agree to be responsible for any charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital).

Your Pet's Name*

Your Name*

First NameLast Name

Phone Number:*

Failure to be reached today may result in cancellation or delay of your pet's procedure.

Alternate Contact Name (if applicable)

First NameLast Name

Alternate Contact Phone:

If you are unable to be reached this person may be asked to make decisions for your pet.

Pre-Anestheic Testing Information

PLEASE READ CAREFULLY.

Our greatest concern is the well-being of your pet. Your pet is scheduled for a procedure that requires anesthesia or sedation. Prior to anesthesia, a veterinarian will perform a basic physical examination to identify any existing medical conditions that could complicate the procedure & compromise the health of your pet. There is a possibility that a physical exam alone will not identify all of your pet’s health problems. Therefore, pre-anesthetic testing can be performed and is always recommended prior to anesthesia. Blood tests can reduce the risk of complications as well as identify medical conditions that could require medical treatment in the future. At our hospital, animals over the age of 5 years are required to have a blood test prior to anesthesia unless otherwise specified by the veterinarian. We also highly recommend chest radiographs on patients7 years of age or older.

The Pre-Anesthetic Blood Profile helps alert the veterinarian to the presence of dehydration, anemia, infection, diabetes and/or kidney or liver disease that could complicate the procedure. These conditions may not be detected without a pre-anesthetic profile thus not allowing for the most appropriate and safest anesthetic regime to be administered. These tests are similar to those your own physician would run if you were to undergo anesthesia. In addition, these tests may be useful if your pet’s health changes to develop faster, more accurate diagnoses and treatments.

Please Select the Following Options for Pre-Anesthetic Testing:

If your pet is in for anesthesia/surgery, there are inherent risks that are unavoidable. We will perform a full physical examination on your pet before administering the anesthesia. However, we highly recommended a pre-anesthetic blood profile to be performed for the purpose of ensuring that your pet has normal major organ function before anesthesia. This includes indicators of anemia, dehydration, kidney function, and liver function. By performing this pre-op blood profile, we will be better able to rule out pre-existing internal problems that may not be evident physically but could lead to serious complications. If you decline the pre-anesthetic blood testing, you accept all risks and responsibilities that go with West Coast Animal Hospital not having the benefit of the blood testing results.

$183 Pre-Anesthetic Profile plus CBC (recommended) *

Includes the test described above plus a complete blood count (CBC). This measures HCT (Anemia), White Blood Cell Count (Infection or Inflammation) & Red Blood Cell Count (Anemia/Bleeding Disorder)

$279 Pre-Anesthetic 3-View Chest X-Ray*

This may be included in your estimate. Chest radiographs are recommended for senior pets. They will be performed before anesthesia and reviewed by the doctor, chest radiographs allow us to view your pet's lungs and heart to check for any abnormalities and ensure they are safe to go under anesthesia.

$74.39 Add-On 4DX Parasite Screen (dogs only)*

Whether on preventatives or not, we highly recommend this test be performed annually starting at 6 months of age. This checks your pet for heartworm and 5 other potentially deadly diseases.

$72.87 Add-On FeLV/FIV Test (cats only)*

We highly recommend this test be performed on all feline patients at least once in their lives because Feline Leukemia and Feline Immunodeficiency Virus (Feline Aids) are viruses for which no cure exists. Please ask questions if you would like to learn more about Feline Leukemia and Feline Aids.

Additional Procedures: Please mark any of the following additional procedures you would like performed while your pet is sedated or anesthetized today.*

Our procedures include cold laser therapy. Cold laser therapy reduces inflammation, pain, and promotes healing so that your pet recovers more quickly.

Yes, Thank you for using laser therapy.

Dental & Surgical Information

Your pet will be undergoing a dental cleaning procedure today which will be performed under general anesthesia. After your pet is anesthetized, a veterinarian will perform a thorough examination of the oral cavity, an experienced veterinary technician will scale and polish the teeth using advanced dental equipment similar to what your dentist uses. If indicated, the veterinarian will order x-rays of the teeth, and will recommend extraction of severely diseased or unsalvageable teeth. Only a veterinarian or a licensed registered veterinary technician (RVT) may perform dental extractions with veterinary supervision.

Anesthetic Procedure

We use a combination of pre-anesthetic medications/injectable and/or inhalant anesthetics to achieve optimum levels of anesthesia and pain control that are safe for your pet. Your pet is anesthetized and then intubated (insertion of a tube into the trachea or wind pipe). This will ensure that your pet is able to receive oxygen at all times and prevents aspiration of any fluids into the lungs. Anesthesia is maintained with a gas anesthetic, Isoflurane, which is very safe. Our experienced veterinary technicians will adjust the anesthesia as directed by the veterinarian.

Monitoring & Pain Management

Throughout their procedure and stay, your pet will be closely monitored by an experienced technician who will utilize our state of the art monitor that records heart rate, pulse rate, oxygen levels, respiration, ECG, and core body temperature. They will assist and alert the veterinarian of any issues before, during, or after the procedure. We strongly believe in compassionate, quality, medical care for our patients. As a result, all dental patients will receive pain management as needed. Additionally, pain medication may be prescribed to go home. Additional information will be given at discharge. We hope this protocol will reduce any discomfort experienced and aid in a quicker recovery.

Intravenous Catheterization & Fluids

For most procedures, an intravenous catheter and fluid therapy will be administered to help support blood pressure, hydration, aid in anesthetic recovery, and have quick access to the circulatory system in case of an unforeseen emergency. We will have to shave a small patch of fur on your pet’s leg to do so.

Potential Risks/Complications for Common Surgeries

Spay: Bleeding, Infection, Suture Material Reaction, Recurrent Heat, Urinary Incontinence, Weight Gain

Neuter: Bleeding, Infection, Scrotal Swelling, Suture Material Reaction, Weight Gain

Tumor/Lump Removal: Bleeding, Infection, Swelling and Drainage, Tumor Re-growth, Suture Material Reaction

Potential Risks/Complications for Dental Procedures

Bleeding from Gums, Infection, Oral Discomfort, Swelling

It is important for you to understand that there is always a risk of anesthetic and surgical complications anytime these procedures are performed. We strive to take the highest quality care of your pet and take all the added precautions you allow to avoid potential problems. Thank you for entrusting your pet’s care to us.

In the rare event that your pet should experience cardiac or respiratory arrest while in our care today, do you consent to resuscitative efforts to be initiated until you can be contacted further about your pet's status? By consenting to this service, you are also acknowledging that additional fees may apply. If we are not able to reach you, resuscitation efforts will be performed at the doctor's discretion. Please choose ONE option below:*

I agree to CPR being performed in case of arrestI elect a Do Not Resuscitate status in case of arrest

DENTAL EXTRACTIONS: Please check ONE of the following. Due to the nature of working with animals it is often difficult to anticipate the exact number of extractions that may be necessary prior to your pet being anesthetized. In the event that your pet will require diseased, infected, painful & unsalvageable teeth to be extracted, we require your consent prior to doing so.*

Signature*

Date*

Date

Cancellation Policy: 24 hours notice required for any cancellations. I agree to a $200 fee for no show or late dental/surgery cancellations.

Initial for Financial Consent

I have received, reviewed and approved the surgical and dental procedure estimate presented to me within the last 30 days.

Initial for Financial Consent

I was advised that my pet needed to be fasted prior to having anesthesia. My pet has not been fed any food for the past 12 hours. If I chose to reschedule the procedure due to my pet eating this morning then I agree to pay a $100 rescheduling fee. Water is ok for my pet to have.

Initial for Financial Consent