Dental Procedure & Anesthesia Consent Form

Dental Procedure Information & Consent

So that we may perform a thorough oral exam, dental radiographs (X-rays), professional dental cleaning, and/or oral surgery, your pet will be under general anesthesia for a period today. For your pet's comfort and safety, she/he will receive oxygen and anesthetic gas through a breathing tube and receive intravenous (IV) fluids and medications. We will provide oral and written discharge instructions for aftercare of your pet at home. Please read the following information, then complete and submit the form. If you have any questions, please let us know.
Pet's Name*
Your Name*

First NameLast Name
Phone number where you will be reachable on the day of your pet's dental procedure*
Please enter a valid phone number.
Contact preference today*

Phone callText message
Emergency Contact - Please provide the name of someone you authorize to make medical decisions in your behalf if we cannot reach you at the phone number listed above.

First NameLast Name
Phone Number for Emergency Contact listed above.
Please enter a valid phone number.
Anesthesia & Sedation - Informed Consent

I understand that during anesthesia, dental procedures, or recovery, unforeseen conditions may be revealed that necessitate an extension of the procedure, or even procedures different than those set forth in the Treatment Plan. I understand that if I request, as indicated below, an attempt will be made to reach me by telephone for permission prior to any additional procedures or services, unless an emergency situation with my pet prevents it. In case of emergency, I hereby consent and authorize the performance of such procedures as necessary and desirable in the exercise of the veterinarian’s professional judgment to treat and maintain my pet’s health. If I cannot be reached, additional non-emergency procedures will not be performed unless I have given prior permission. I understand that I am responsible for any additional charges if additional services are provided.

I have been advised of the nature of the services and procedures included in the Treatment Plan, as well as the risks involved, including death. While I expect all procedures to be performed to the best of the staff’s abilities, I realize that medical results cannot be guaranteed.

In the case of emergency and in the event I cannot be contacted in time, I authorize Laura Monahan, DVM, and/or her agents to perform any additional diagnostic, therapeutic, or surgical procedures necessary for treating and maintaining my pet’s health and comfort. I expect Dr. Monahan and/or her agents to use reasonable precautions to ensure my pet’s safety, and I agree to pay in full for all services provided when my pet is discharged.

I have reviewed and accept the proposed Treatment Plan presented to me. I understand that a 50% deposit is due when my pet is admitted for treatment/surgery and that the remainder of the invoice is due in full at discharge. I understand the cost estimate may not be a complete representation of my final bill if additional procedures are performed.

Dogs Owners: I understand that feeding my dog a grain-free, raw, or homemade diet may increase the risk of sudden death because of a medical condition called Dilated Cardiomyopathy, a very serious - but often undetectable - heart condition that may be associated with feeding these type of diets.
Emergency Directive:*

Yes to CPR with a Financial Limitation of $315-475 (CPR, Emergency drugs, and Medical team care)Yes to CPR with a Financial Limitation of $500-715 (CPR, Emergency drugs, Intubation & oxygen support, IV catheter, and Medical team care)No, Do Not Resuscitate (DNR)
If, after a thorough oral exam and dental radiographs (X-rays), the doctor determines pet your needs additional dental extractions beyond what you've authorized on the Treatment Plan, please indicate your preferred choice below:*

Try to reach me at my phone number listed above; if you can't reach me, please do whatever the doctor determines to be medically necessary. I understand I will be responsible for additional charges.No need to contact me. Do whatever the doctor determines to be medically necessary. I understand I will be responsible for additional charges.If I cannot be reached, I do not authorize any additional extractions beyond what was stated on the HIGH END of the Treatment Plan. I understand my pet may require an additional anesthetic procedure at a later date to address diseased teeth.If I cannot be reached, I do not authorize ANY extractions. I understand my pet may require an additional anesthetic procedure at a later date to address diseased teeth.
Has your pet eaten anything (including treats) in the past 8 hours?*

YesNo
Is your pet taking any medications, vitamins, or supplements? If so, please list all medications below - this is very important to the safety of anesthesia.*

YesNo
Please list all medications, vitamins, and supplements your pet is taking. If none, please type "None."*
Has your pet experienced any unreported illness or injury in the past 90 days?*

YesNo
Are you aware of any problems with anesthesia or seizures in the past?*

YesNo
May we offer your pet a light meal later today if she/he appears hungry and is medically stable?*

YesNo
Does your pet have any dietary restrictions? If so, please list below.*

YesNo
My pet cannot eat the following:
I authorize the following complimentary services for my pet while under anesthesia:*

Complimentary nail trimComplimentary anal gland expressionNo thank you, neither one
By signing below, I acknowledge that I have been advised and accept the inherent risks involved with anesthesia. I consent for my pet to receive anethesia or sedation today. While I expect all procedures to be performed to the best of the staff’s abilities, I realize that medical results cannot be guaranteed. I also understand that if complications arise, there may be additional medical care and costs required.

Yes
Date*

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Date
Signature*

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Dental Procedure Information & Consent