Dental Surgery and Anesthesia Consent Form in Farmington, MN

Dental Surgery and Anesthesia Consent Form

Client Name*

First Last

Email*

Patient ID

Allergies*

Date*

Patient Name*

Species*

Breed*

Color*

Sex*

Male
Female

Date of Birth*

Weight*

Doctor*

Phone*

Today’s Phone Number:*

(This number needs to be reliable to reach you while your pet is under anesthesia.)

If Extractions ($23-$62/tooth) are needed, please choose how you want us to proceed:*

1. Perform what is medically necessary.
2. Please call the phone number above.

If I am unavailable when you call, please:

a. Proceed with any medically necessary procedures
b. Do only what I have authorized. (I understand by doing so, a second procedure may be needed to complete the necessary treatment for my pet.)

Is your pet on any medications?*

Yes
No

What medication, dose, and the last time it was given?*

Is your pet allergic to any medications?*

Yes
No

Please list:*

As the owner or agent of the animal listed above, I hereby give my consent to Akin Hills Pet Hospital to perform the dental cleaning and polishing.

If your pet is to be anesthetized, be assured that advances in anesthesia and surgery have been made for routine procedures relatively safe with a low rate of complications. Nonetheless, occasionally problems can arise due to pre-existing conditions that may not be noticed during the pre-anesthetic examinations. To avoid these problems, we recommend all pets to be screened prior anesthesia by the following laboratory tests.

1. Pre-anesthetic Blood Screening: : organ function tests, packed red blood cell & total plasma protein measurements.

2. IV catheter and Fluids: : aids in adequate blood pressure and gives immediate access to the vein if an emergency arises.

The following options are optional. They will be performed (and you will be charged) unless you refuse them and initial below.

Heartworm Test*

(dogs, if not up to date or on heartworm preventative)

Yes
No

Do you need Heartworm Preventative?*

Yes
No

Feline Leukemia/FIV test*

(If your cat is not up to date on vaccines or an outdoor cat)

Yes
No

Home Again Microchip*

Aids in your pet being returned to you if your pet gets lost.

Yes
No

Do you consent to a 3-5 minute ultrasound on your pet?*

We are currently learning a new technology and trying to become more knowledgeable and comfortable looking at normal anatomy on ultrasound. This would be at no extra charge to you and would only be done if your pet is stable under anesthesia.

Yes
No

Rabies Vaccine:*

A current rabies vaccine is required for all pets at our clinic.

I’m aware of this requirement and have proof of vaccination or I am giving Akin Hills Pet Hospital authorization to give the vaccination.

We agree to fast our pet overnight, with no food after 10 PM (can offer water)*

Yes

I understand that during the performance of this procedure, unforeseen conditions may be revealed that can delay or change the procedure set forth above. I expect Akin Hills Pet Hospital to use reasonable care and judgment in performing the procedure. The nature of the procedure and the risks involved, including death, has been explained to me and I realize results cannot be guaranteed therefore, I will not hold Akin Hills Pet Hospital liable if something happens to my pet. I am also aware that unforeseen events resulting from the procedure will not relieve me from any obligation to all reasonable costs incurred regarding my animal.*

Yes, I do understand.

Signature*