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(770) 642-1282
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Roswell, GA, 30076
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today:2023-12-09
Dental & Oral Surgery Consent Form
Welcome! Prior to your pets upcoming surgery, please fill out the form below.
Please enable JavaScript in your browser to complete this form.
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Step
1
of 5
Client's Name
*
First
Last
Pet's Name
*
Phone Number
*
Please provide the number where you can be reached during the procedure.
When did your pet last eat or drink?
*
Please list any known allergies or adverse reactions to anesthetics or drugs.
*
Example: Vomiting, diarrhea, swelling, hives, etc.
Dental Procedure
This is a professional oral health exam, treatment and teeth cleaning for your pet. This procedure includes an oral cancer screening, digital dental x-rays (when indicated) which help diagnose dental and oral disorders, irrigation (cleaning the mouth with an antibiotic solution), hand and ultrasonic scaling and polishing, possible surgery based on oral exam findings, and is performed under general anesthesia.
Would you like to add on any procedures?
*
Yes
No
If Yes, Please describe in the field below.
List any add-on procedures:
Next
Pre-Anesthetic Blood Profiles
In an attempt to minimize risks associated with anesthesia, we advise that pre-anesthetic blood work be performed, even for elective procedures. Since our pets cannot alert us to problems, these tests give us valuable information to help assess your pet’s health. If the results of the blood screening show any problems with the vital organs that would cause us to delay today’s procedure, we will contact you. If the test results are normal, they are still valuable as they provide us with your pet’s baseline normal results for comparison should your pet become ill in the future.
Do you accept the option for us to perform Pre-Anesthetic blood profiles?
*
ACCEPT
DECLINE
ALREADY PERFORMED
Please make sure you read the description on Pre-Anesthetic Blood Profiles above before selecting.
Chest Radiographs (Evaluating Heart and Lungs)
If your pet is over 5 years of age, we recommend chest radiographs be performed to evaluate the heart and rule out hidden lung problems.
Do you accept the option for us to perform a Chest Radiograph?
*
ACCEPT
DECLINE
ALREADY PERFORMED
Please make sure you read the description on Chest Radiographs above before selecting.
Additional Treatments and Services
*
Anal Glands Expression
Nail Dremel
Cold Laster (Accelerates Post-Surgery Healing)
Nail Trim (Complimentary)
Ear Cleaning
Microchip
None
Other
If Other, please explain in the field below.
Other:
Next
Consent for Anesthesia and Sedation
While your pet is under anesthesia we maintain a constant record of vital signs including heart rate, respiratory rate, oxygenation levels, blood pressure, and temperature. This helps us to detect potential anesthetic complications early and treat them before they become life threatening. An intravenous catheter may be placed for the safety of your pet, and used as a means to deliver anesthetic medication and fluids during anesthesia. This helps to maintain blood pressure and allow administration of drugs should an emergency situation develop. Your pet’s limb(s) will be shaved in order to sterilely place the intravenous catheter. Bruising, swelling and clipper burn at the catheter site may occur.
Single Line Text
I acknowledge that my pet may have an underlying condition that has not been detected with diagnostic tests/tools to date, and I further understand that during the course of the procedure(s), unforeseen conditions may arise that could necessitate the performance of additional procedures. (PLEASE INITIAL)
*
Please initial in the field above.
Although rare, I acknowledge that unexpected severe complications with anesthesia can occur. In addition, risks of all anesthetics may include, but are not limited to; low blood pressure, low oxygenation leading to stroke, vomiting or regurgitation leading to aspiration and pneumonia, infection, bleeding, drug reactions, blood clots, corneal abrasions and ulcers, damage to veins, arteries or nerves, brain damage, or death. (PLEASE INITIAL)
*
Please initial in the field above.
To help avoid nausea and risk of subsequent vomiting under anesthesia leading to aspiration pneumonia, we recommend giving a pre-anesthetic antiemetic drug (i.e. Cerenia).
*
ACCEPT
DECLINE
Consent for Dental and Oral Surgery
I acknowledge that complications associated with dental procedures may occur. These complications include, but are limited to, infections of the gums, extraction sites or systemic infections, pain and anorexia, (depending upon extent of extractions and/or oral surgery), recurrence of periodontal disease, (dependent upon aggressiveness of prevention), bleeding of gums (should resolve in 1-2 days after procedure), unintended fracture of the jaw during extractions, and nerve damage associated with local anesthetic blocks. (PLEASE INITIAL)
*
Please initial in the field above.
I grant the doctors permission to extract decaying or diseased teeth if medically indicated (this will avoid a second anesthetic procedure to address existing problems discovered during today’s treatment). (PLEASE INITIAL)
*
Please initial in the field above.
An attempt to call you will be made if extractions or treatment of periodontal pocketing is recommended.
If you are unreachable, a decision will be made using our best medical judgment in your pet’s best interest (see below to accept or decline).
I acknowledge that if the dental disease found is minimal, every attempt will be made to avoid extraction including treating gingival pockets with medication. If extractions are needed, the charge for extraction will vary based on the difficulty of the extraction. Additional anesthesia may also be charged if the procedure becomes extended. If pain management is indicated as a result of the procedure, analgesics will be administered. The cost for pain management varies on a case - by - case basis based on individual patient needs to ensure comfort.
*
Please initial in the field above.
Next
Acknowledgments and Aggreements
I have been informed that there are risks and complications associated with anesthesia and surgery. (PLEASE INITIAL)
*
Please initial in the field above.
I release East Roswell Vet Hospital and staff from any liability relating to unforeseen complications arising from surgery and/or anesthesia. (PLEASE INITIAL)
*
Please initial in the field above.
I will be available at the phone number(s) listed at all times during the day of the procedure. If the doctors and staff cannot reach me by phone, I authorize any treatment deemed necessary for the health of my pet.
*
I DO
I DO NOT
I authorize treatment as deemed by the doctor over and above the treatment discussed, up to an ADDITIONAL $______________. I will only be called if such a treatment that exceeds this amount. (PLEASE LIST ADDITIONAL DOLLAR AMOUNT & INITIAL)
*
Please enter a dollar amount of additional funds you are willing to spend and initial in the field above.
If you declined the above statement, and you are requesting that we contact you prior to the performance of ANY additional treatment, you must accept the following: I fully understand that my pet will be under anesthesia longer and I accept responsibility for increased medical risk and/or cost. I also understand that if I cannot be contacted within a reasonable amount of time that my pet will be wakened from anesthesia. If I choose at a later time to have the procedure performed, it will require additional anesthesia and cost. (PLEASE INITIAL)
*
Please initial in the field above.
I hereby authorize and direct the veterinarians and staff to perform the procedure(s) described above. The nature of the procedure and risks involved have been explained to me, and I realize results cannot be guaranteed. I am also aware the unforeseen events resulting from the procedure(s) will not relieve me from any obligation to all reasonable costs incurred regarding my pet. (PLEASE INITIAL)
*
Please initial in the field above.
Next
Financial Agreement
I understand that the treatment of my pet will be conducted with due care and in accordance with the prevailing standards of competence in veterinary medicine. I certify that no guarantee or assurance has been made as to the results that may be obtained through the course of treatment undertaken by the veterinarians and staff of East Roswell Vet Hospital. I understand that a written estimate of charges is available within reasonable time of my request, and that costs for antibiotics dispensed, pain management, additional anesthesia time and extractions may not be included on this estimate; these charges are assessed on an individual basis which may vary. In order to continue to provide the highest quality of veterinary medicine, we require payment in full at the time services are rendered. I assume financial responsibility for all charges incurred to the patient services rendered, and understand that full payment is required upon completion. I certify that I have read and understand this release, and furthermore that I assume full responsibility for all charges related to the above procedures. I am the owner (or agent for the owner of legal age) for the animal described above and I have the authority to execute this consent.
Owner's Name
*
First
Last
Signature
*
Date
*
Phone Number
*
Alternate Phone Number
ADVANCE DIRECTIVE (CPR VS DNR)
I authorize the doctor to conduct CPR without my prior consent.
*
I DO
I DO NOT
***Additional fees will accrue to perform CPR
Submit
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