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Client FormAnesthesia & Dental Consent Form

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Anesthesia & Dental Consent Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.
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Has patient been fasted overnight?(Required)

Dental Extraction Consent Form / Pre-Authorization

Our veterinarian will perform a full oral evaluation and dental x-rays for your pet while they are under general anesthesia today. If extractions/additional treatments are deemed necessary, we will require your verbal consent.. You must be available be telephone at all times today. The phone number(s) where you can be reached today:

*required by the DEA for certain medications given to pets

As a full service veterinary hospital, we are pleased and proud to offer you the best medical care available to your pet. Your pet's health is of utmost priority to our dedicated staff, and we take all possible precautions to ensure their safety and comfort. Although rare, unexpected complications with general anesthesia can occur. Damaged teeth often cause pain and disease in the mouth and at sites distant to it. Damaged teeth usually require surgical extraction to promote good oral health. Often, in pets with significant periodontal disease, numerous teeth must be extracted. As in other types of surgery, oral surgery techniques are designed to facilitate healing and minimize pain. Costs vary from $90.00 for a simple extraction to $150.00 per tooth for a complicated extraction (includes local anesthetic and extraction).

Surgical/Anesthesia Information:

As a full service veterinary hospital, we are pleased and proud to offer you the best medical care available to your pet. Your pet's health is of utmost priority to our dedicated staff, and we take all possible precautions to ensure their safety and comfort. Although rare, unexpected complications with general anesthesia can occur.

1. Bloodwork & ECG: All pets undergoing anesthesia at ABC Veterinary Hospital Pacific Beach have pre-anesthetic blood testing performed to look at basic organ function and to tailor anesthetic medications used. This will also check for pre-existing medical conditions, which may increase the risk of complications during surgery. Additionally, an electrocardiogram will be performed to determine the health of your pet's heart.

2. IV Catheter:Your pet will have a portion of their leg(s) shaved to all an intravenous (IV) catheter to be placed. This provides immediate access to your pet's circulatory system for rapid administration of drugs should an emergency situation arise. Your pet may also be administered intravenous fluids to help maintain normal blood pressure, protect vital organs, and maintain proper hydration.

3. Pain Control: All pets undergoing surgery will receive pain injections while at the clinic (which was in the initial quote). Postoperative pain management is a concern for all surgical procedures. Most procedures merit at-home oral medication for several days after surgery and will be dispensed at the veterinarian's discretion.

4. Flea treatment: For the health and safety of all of our hospitalized pets, all pets housed at our facility must be free of fleas. If fleas or evidence of fleas are found on your pet, an oral rapid-acting flea treatment will be administered (Capstar) at the owner's cost (17$)

Additional elective procedures offered (please check services that you would like performed)(Required)

Surgical/Anesthetic Consent Waiver:

The nature of the procedure and the potential risks, have been explained to me and I understand the procedure(s) to be performed. I understand that some risks always exist with anesthesia, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. My signature on this consent form indicates that any and all my questions have been answered to my satisfaction.(Required)

Cardiopulmonary Resuscitation (CPR) Directive

While anesthetized or hospitalized, If your pet suffers respiratory arrest (stops breathing) or cardiac arrest (the heart stops), we need to know your wishes concerning treatment. If either respiratory arrest or cardiac arrest occurs, your pet will die unless immediate resuscitation attempts are started.(Required)

I understand ABC Veterinary Hospital Pacific Beach requires a CPR status when my pet is left in their care. I acknowledge that the attending veterinarian or staff members of ABC PB will make every effort to contact me regarding treatment in the case of this unforeseen event. The initial cost of CPR, Oxygen and Emergency Injections start at approximately $800.

CPR means “Cardio Pulmonary Resuscitation” and is the treatment (resuscitation) of a pet who has stopped breathing or whose heart has stopped beating. Resuscitation of a pet who has stopped breathing but still has a heartbeat is more likely to succeed than resuscitation of a pet with no heartbeat.

DNR means “Do Not Resuscitate.” This means that if a pet stops breathing or his/her heart stops, no effort will be made to attempt to revive the pet, and the pet will die.

I am the owner / agent of this pet and ...(Required)
I hereby request ABC Veterinary Hospital Pacific Beach to anesthetize and perform a dental prophylactic procedure on my pet. While ABC Veterinary Hospital Pacific Beach provides the highest quality of anesthesia monitoring and surgical services, I understand the risks and understand that the veterinarians and hospital team will do everything possible to minimize any risks. I understand the hospital support personnel will be used as deemed necessary by the veterinarian. Not withstanding the risk, I request the surgery and waive any and all claims of damage against ABC Veterinary Hospital Pacific beach, its officers and employees, in the event of injury or death of my animal.(Required)
I am aware that charges for extractions and/or antibiotics, if deemed necessary by the veterinarian, will be at an additional cost. I understand that my veterinarian will contact me at the phone number(s) listed above for consent prior to additional treatments/extractions being performed. If I am unable to be reached by telephone, the veterinarian will make every attempt possible to contact me for a maximum of 15 minutes, after which my pet will be woken up from anesthesia.(Required)
I understand that payment is due at time of service with the exception of surgery/anesthesia/dental deposit, which is paid at the time of patient drop-off. I understand that as the owner or agent, I am financially responsible for all charges relating to this patient. I have read and agreed to this treatment authorization and have agreed to the financial obligations.(Required)

Dental Extractions & Consent:

Tooth extractions are often necessary in pets with moderate to severe dental disease or fractured teeth. These can vary from minor single rooted incisors and premolars to major (double and triple rooted) premolars and molars. Some major tooth extractions may also require gingival tissue surgery. Most extractions also need additional anesthetic time, which is at additional cost. Dental X-rays are required for all extractions.

I authorize all medically necessary extractions to be performed, regardless of cost and I do not need to be contacted. I am aware that the costs can be up to $2,500 additional to my estimate.(Required)
I authorize any extractions medically necessary, incurring an additional amount to my estimate already provided but would prefer to be called first. I understand if I cannot be reached within 15 minutes, I elect to let the Veterinarian proceed with medically necessary extractions and the amount I authorize for additional treatments and costs are:(Required)
If I cannot be contacted by phone within 15 minutes, I do not authorize any extractions to be performed. I understand that by checking this, my pet will be woken up from anesthesia and may need another procedure to perform extractions as needed. *Please be aware that if you decline any needed procedures at this time, your pet would need a second anesthesia at another time in order for those procedures to be performed.(Required)

I authorize the use of anesthetic drugs and/or gas anesthesia to be used on my pet. I understand that while the anesthesia used in this hospital is safe for use in veterinary medicine, no anesthesia is without medical risks. No guarantee can be made legally or ethically on the outcome of any procedure performed. The nature of the procedure(s) has been explained to me fully and my questions have been answered to my satisfaction. I understand that there are some risks involved in all procedures and that no guarantee for success can be given. If I am unable to be reached by telephone, the veterinarian will make every attempt possible to contact me for a maximum of 15 minutes, after which my pet will be woken up from anesthesia.

I agree to pay in full for services rendered, including those deemed necessary for medical and/or surgical complications or unforeseen circumstances. I have read and understand this consent. I understand that any estimate is an approximation, and that the actual cost may be greater or less. This hospital accepts Cash, Care Credit and Credit Cards. All payments are due at the time of my pets discharge.(Required)

By signing below, I am stating that I am the primary owner on my account with ABC Veterinary Hospital Pacific Beach.

*If the primary is not available for signature in person, this form is to be emailed to them for esignature prior to the start of the dental.

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