Dental Anesthetic Consent

Dental Anesthetic Consent
Your pet is scheduled for a dental scaling and polishing, which requires general anesthesia.
Name*
First NameLast Name
Your Pet's Name*
Best number to reach you at on the day of your pet's procedure:*
Area CodePhone Number
When did your pet last eat?*
Does your pet have any known allergies?*
In the past 48 hours, please select if your pet has experienced any of the following:*
CoughingSneezingVomitingDiarrhea
Is your pet on any medications, if so, please list the medications and when they were last given.*
Do you have any additional concerns for the doctor today?*
Please select any services you would like performed while your pet is under anesthesia:
Toe Nail Trim ($6)Anal Gland Expression ($30.12)Microchip ($58.59)Flea or Internal Parasite Preventative (price varies)
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 procedures 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:*
Please proceed with life-saving measures. I will accept responsibility for all costs incurred.Please do not proceed with life-saving measures. I accept responsibility for all costs incurred.
Please select one of the following:*
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 vary 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, your 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.
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 required prior to 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. Comprehensive Blood Panel: This is the most complete blood screen available using our in-hospital laboratory. This panel includes: red blood cell counts, white blood cell counts, a check on kidney and liver function, electrolyte levels, and an additional pancreatic function test. If your pet has not had a comprehensive blood screening performed and reported as ‘normal’ within three months of their scheduled anesthesia/sedation, this test will be run the morning of their procedure. I, (or agent acting on owner’s behalf) hereby authorize Brookfield Veterinary Hospital (or its agents or whomsoever is designated) to perform the above procedure. I understand that there are inherent risks with anesthesia and that a guarantee of a successful outcome cannot be made. These risks have been explained to me as completely as possible within reason. I also understand that Brookfield Veterinary Hospital will do their best to minimize these risks through pre-anesthetic blood testing, using the most appropriate and safest anesthetics available, and by using state of the art monitoring equipment. Furthermore, I agree to pay the fees for all services rendered at the time the pet is discharged from the hospital. Please sign recognizing that you have read and understand the risks.
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