Owners Name *

First

Last

Email *

have procedure While

Pet Name: *

Date of Procedure *

Procedure(s) to be performed *

*This may not include the pre-ops or additional treatments included on your estimate; instead, this is only intended to list the name/type of the procedure

Has patient been fasted overnight?

List of current medications: *

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 by telephone at all times today. The phone number(s) where you can be reached today:

Phone 1 *

Phone 2

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 from 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:

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.
Pre-Operative X-Rays: All pets undergoing anesthesia at ABC Veterinary Hospital Pacific Beach, who are 8 years or older are required to have pre-operative chest X-rays to evaluate heart size, shape, and lungs. If any patient has a heart murmur noted in their medical history, this is not optional unless discussed with a veterinarian beforehand.
IV Catheter: Your pet will have a portion of their leg(s) shaved to allow 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.
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.
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) *

Elizabethan collars ($15-25) highly recommended with most surgeries. These collars dramatically reduce the risk of your pet removing bandages and sutures that may result in additional surgery/cost to you. Please note: soft "donut" collars are not recommended.
Nail Trim (price included with Anesthetic Procedures, please authorize it by checking the box)
Anal Gland Expression ($32)
Microchip Implantation ($71)
None of the above to be added

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. *

I understand

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. *

I understand

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 starts 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 ... *

I AUTHORIZE CPR and Emergency Efforts for my pet
I DO NOT AUTHORIZE CPR and Emergency Efforts (DNR) for my pet

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. *

I understand

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. *

I understand

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. *

I understand

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 an 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 $3,500 additional to my estimate. *

Yes, I authorize all medically necessary extractions and do not need to be contacted
No, I do not authorize all medically necessary extractions and do need to be contacted

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:

I already authorized all medically necessary extractions, understanding it could amount to an additional $3,500

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. *

I understand I am authorizing NO extractions without my consent, and my pet will be woken up from anesthesia if I am unreachable
I have authorized one of the two options above already

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 awakened 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, CareCredit and credit cards. All payments are due at the time of my pet's discharge. *

I understand

I understand that if for any reason anesthesia and/or the procedure my pet came in for today was not completed due to abnormalities on bloodwork or preoperative diagnostics, I am financially responsible for charges incurred. *

I Agree and Understand

I understand that by signing this consent, I am consenting for my pet to be left in ABC Veterinary Hospital Pacific Beach's care and to receive the treatments/procedure(s) listed above and have had the opportunity to ask questions about charges. *

I Agree and Understand

By signing below, I confirm that I am the primary owner of 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 e-signature prior to the start of the dental.

Signature *

Clear Signature

Date *

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Anesthesia & Dental Consent Form

Dental Extraction Consent Form / Pre-Authorization

Surgical/Anesthesia Information:

Surgical/Anesthetic Consent Waiver:

Cardiopulmonary Resuscitation (CPR) Directive

Dental Extractions & Consent:

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