Dental Anesthesia Consent Form – Veterinarians Cedar Rapids, IA

Today's Date*

Owner's Name*

First Last

Co-Owner's Name

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Disclaimer

Your pet will be scheduled for a procedure that requires anesthesia. Though very unlikely, anesthesia inherently carries some risk. Therefore, we would like to take this opportunity to explain why pre-anesthetic blood testing will be performed and why it is important to the health of your four legged family member. The anesthetic agent is removed from the body by the liver and kidneys, so it is important to know before anesthesia that these organs are functioning well. Like you, our greatest concern is the well-being of your pet. Before putting your pet under anesthesia, a veterinarian will perform a full comprehensive physical examination to identify any existing medical conditions that could complicate the procedure and compromise the health of your pet. There is always the possibility that a physical exam alone will not identify all of your pet’s health problems. The pre-anesthetic blood profile (a combination of blood tests) is performed prior to anesthesia. This blood profile that we complete in our lab is similar to, and equally as important as those your own physician would run if you were to undergo anesthesia. Results will be immediately available before general anesthesia and/or surgery. It is important to understand that a pre-anesthetic blood profile does not guarantee the absence of complications. It may, however, greatly reduce the risk of complications that could require medical treatment in the future. If your pet is geriatric or ill, we strongly recommended upgrading to a full comprehensive blood screening.

Bloodwork Consent

Yes, I want to upgrade my pet’s blood work and have a full comprehensive blood screening at an additional cost of $190.50 (Includes all of the pre-anesthesia blood work, as well as, thyroid function, protein levels, calcium, phosphorus) ***Strongly recommended for patients over 8 years of age.
No, I would not like to upgrade my pet's blood work

ECG Safety Option for All Pets:

An electrocardiogram (ECG) is an advocated safety option for all pets prior to general anesthesia as part of the pre-surgical work-up. An ECG is a diagnostic tool used to screen patients for the presence of hidden heart disease and/or arrhythmias that can form at any age. ECG's are conducted the morning of surgery and are evaluated by board-certified cardiologists prior to surgery. Anesthesia protocols are often based on the findings of these reports. ECG's are optional, but highly recommended tools to ensure a favorable outcome for your pet's procedure.

ECG Consent*

Yes, I want my pet to have a pre-anesthesia ECG at an additional cost of $114.50
No, I decline at this time for an ECG to be performed.

AKC Identification Microchip for All Pets:

Reuniting lost or stolen pets with their owners is an increasing problem. The AKC Identification Microchip can help alleviate this problem. This small chip, implanted between your pets' shoulder blades, will allow veterinary hospitals, shelters, and law enforcement to identify your pet and contact you.

AKC Consent*

Yes, I want my pet to receive the AKC Identification Microchip at an additional cost of $70.00
No, I decline at this time a microchip implant.

Authorization for Possible Extraction(s)

Dental disease may not reveal itself until a thorough exam under general anesthesia is performed. Dental radiographs are utilized to assess disease below the gum line during this exam. Every attempt will be made by the doctor to preserve your pet's teeth, however, in cases where extractions are required these are done with your pet's health and best interest in mind. Common reasons for surgical extractions include broken teeth, abscessed roots, damaged sockets, cyst formation, and so on.

Tooth Extraction*

Yes, I authorize the extraction of diseased teeth, should they be found, while my pet is having a dental. The cost of the extraction is based on time and degree of difficulty.

I prefer to be called before any additional procedures, other than emergencies. If I cannot be reached, I DO authorize you to proceed with any procedures as deemed necessary by the doctor. The best number I can be reached at (please enter phone number below):

If I cannot be reached by phone, I DO NOT authorize any additional procedures.

Please check each space indicating that you acknowledge the following statements:

Our practice understands the importance of pain management and control for our patients. If indicated we will be administering additional pain relief medication, and there will be a corresponding charge on your bill.*

Yes, I have read the above statement and understand.

In almost all cases, a small area on the front leg will be shaved and an IV catheter will be placed for the surgical procedure. This allows our staff to administer medications and provide fluid therapy while your pet is under anesthesia.*

Yes, I have read the above statement and understand.

MISC: Please list the name and indicate the time the last dose was given for any medication your pet is currently on.

Please bring these medications with you on the day of surgery.

Name of Medication

Date of Last Dose

Any other Medications?

Yes
No

Name of Medication #2

Date of Last Dose #2

Name of Medication #3

Date of Last Dose #3

How would you like to be contacted?:

I understand that there are risks associated with anesthesia and the procedures set forth above, and with anesthesia. An I am satisfied after speaking with the staff of Frey Pet Hospital that they will treat my pet as they deem necessary for their health, safety, and well-being; however I do understand that no guarantee of successful treatment can be made. I acknowledge that I have read and fully understand this Authorization for Medical Treatment, the reason why such medical treatment is considered necessary, as well as, its advantages and possible complications, if any. I understand that payment is due at the time my pet is discharged and that a deposit may be required for extensive medical or surgical procedures.

Pet Name*

Date of scheduled procedure*

Print Name*

Electronic Signature*

Emergency Phone Number*

Dental Consent Form