Dental Surgery Consent Form Pet's Name Owner's Name * First Name Last Name Email * It is imperitive that we be able to reach you in a timely manner while your pet is in the building today. Please list the primary phone number where you can be reached. Phone * (###) ### #### If we are unable to reach you, is there someone else we can contact regarding your pet? * If yes, please provide their information below. Yes No Emergency Contact First Name Last Name Emergency Contact's Phone (###) ### #### Please list the reason for anesthesia below * When did you pet last eat? * Hour Minute Second AM PM Has you pet experienced any of the following in the past two weeks? * Coughing Sneezing Vomiting Diarrhea None of the above Has your pet ever experienced any adverse reaction to medication? * Yes No Unsure Does your pet have any history of allergies or an allergic reaction? * Yes No Unsure If yes to either of the above, please provide more detail about your pet's medical history Is your pet current on vaccinations? * Yes No I'm not sure Please provide the last veterinary facility that your pet received vaccinations at? * If your pet is due for vaccines, would you like them updated today? Yes Yes, but I would like an estimate prior to proceeding No Does your pet have a microchip? * Yes No No, but I would like my pet to be microchipped today for an additional cost of $60. Bloodwork * Please check with our technicians if you have pricing questions I accept a basic blood panel (pets 4 years and under) I decline a basic blood panel (pets 4 years and under) I accept an extended blood panel (pets over 4 years) I decline an extended blood panel (pets over 4 years) Please select below * I accept a heartworm/FeLV&FIV test for my pet I decline a heartworm/FeLV&FIV test for my pet I accept a ProBNP test for my pet I decline a ProBNP test for my pet I accept an anal gland expression for my pet I decline an anal gland expression for my pet Please select one of the options below: * Please perform any extractions that the doctor deems necessary. Our goal is to keep within your estimate, however, the nature of dental care is such that we cannot predict everything that may need to be done beforehand. As a result, it is possible for your bill to increase considerably from the original estimate. Please call before performing any extractions. If I am not available, I give permission to do what is necessary. Again, our goal is to keep within your estimate, however, the nature of dental care is such that we cannot predict everything that may need to be done beforehand. As a result, it is possible for your bill to vary considerable from the original estimate. Please call before performing any extractions. I understand that if I am not available, no procedures will be performed without my authorization, even if deemed necessary. Maximum Cost If we are unable to reach you and you selected proceed with the necessary extractions, what is the maximum cost that we can proceed with outside of your estimate? Please list any medications, supplements, topical treatments, or vaccinations that your pet has received in the past 72 hours * Please provide details of dosing and when they were last given. Please list any of your pet's known health concerns, chronic diseases, and/or conditions * Please provide any further information that you would like us to know about your pet An estimate has been provided to me regarding my pet's anesthetic procedure today * Yes, I accept all costs provided within the estimate. No, I would like to see an estimate of the costs before proceeding with anesthesia today. I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize treatment of my pet to be performed by High Country Veterinary Hospital. I authorize the use of anesthesia and other medication as deemed necessary by the attending veterinarian * I accept these terms and conditions. Our greatest concern is the wellbeing of your pet. Before any anesthesia is administered, we will perform a complete pre-anesthetic examination to identify existing medical conditions that could complicate the procedure and compromise your pet’s health. There is always the possibility that a pre-anesthetic exam alone will not identify all health problems. This is why blood testing is highly recommended prior to general anesthesia. This does not guarantee the absence of anesthetic complications. It may, however, greatly reduce the risk of complications as well as identify medical conditions that could require treatment. I have been advised as to the nature of this procedure and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any anesthetic procedure, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. I understand that it may be necessary to provide medical and/or surgical procedures which are 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 accept these terms and conditions. I agree to be responsible for all 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 accept these terms and conditions. In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference below Please proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred. Please do not proceed (DNR) with basic cardiopulmonary resuscitation. I accept responsibility for all costs incurred. Thank you!
