Owner's Name

Owner's Email

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone number owner can be reached at:

Patient Name

Patient's Breed

Patient's Sex

Patient's Age

Patient's Color

Markings:

Please carefully review and select one of the following options:

Occasionally, the admitting veterinarian will find unhealthy teeth in need of removal. I authorize admitting veterinarian to extract unhealthy teeth during the dental cleaning procedure if admitting veterinarian deems necessary for patient’s best care.

I authorize the admitting veterinarian to extract unhealthy teeth during the dental cleaning procedure. We will contact you prior to extraction of patient's teeth, if we cannot reach you by phone, we will commence with extractions.

DECLINE WITHOUT PRIOR NOTIFICATION - Owner or Agent does not authorize extractions without notification.

If you have declined without prior notification, please enter a phone number we can reach you at between the hours of 9am-4pm

Please note that your pet will be under general anesthesia when the veterinary staff calls to authorize the extractions.

We need a contact number that we can reach you at between 9 am and 4 pm.

If we cannot reach you by phone after 10 minutes, we will wake your pet up from anesthesia without performing the recommended extractions.

Please carefully review the following statements. By checking each box, you acknowledge that you have read and understand the statement.

I understand that some risks always exist with sedation, anesthesia and/or surgery, and I have been encouraged to discuss any concerns I may have about those risks with my veterinarian before the procedure(s) is/are initiated. Surgical and anesthetic risks include, but are not limited to, infection at the surgical site, unexpected blood loss, and anesthetic or surgical complications up to and including death.

I authorize the use of appropriate anesthetics and other medications, and I understand that the hospital support personnel will be employed as deemed necessary by the veterinarian. I have been advised as to the nature of the procedures or operations and understand the risks involved and realize results cannot be guaranteed. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures.

I understand that the attached surgical estimate provided to me during my pre-surgical consultation at East Hills Veterinary Clinic does not include any additional costs that I may occur if any possible complications may arise as a result of this surgical procedure. I also understand that I am solely financially responsible for the continued care and treatment of my pets’ complications if any arise as a result from this surgical procedure.

These complications may include but are not limited to:

Vomiting
Abscess from Suture Reaction
Urinary Tract Infection
Diarrhea
Incisional Infections
Seroma Formation
Dehiscence
Dermatitis

I understand it is recommended that the pre-anesthetic CBC and Chem bloodwork be completed less than 30 days prior to surgery.

Pre-anesthetic blood work has been completed.

I authorize this bloodwork to be performed.

I have declined the recommended profile.

I understand this does not give the attending veterinarian a complete profile of internal organ function, and that there may be an underlying disease which could cause greater risk regarding sedation/anesthesia and recovery.

I understand East Hills Veterinary Clinic is not a 24-hour facility and does not have personnel after business hours. I have been given the option to transport my pet to a 24-hour facility such as MedVet or CARE Center at my own expense for overnight monitoring.

In an effort to make anesthesia as safe as possible, we employ the following except where the circumstances of the case require a change in the protocol.

A complete physical exam.

Appropriate pre-anesthesia medications provide for analgesia and relaxation so your pet can go under anesthesia and awaken from it more smoothly, as well as provide adequate postoperative pain control.

Monitoring of vitals during anesthesia and recovery.

If surgery will be performed, when was the last time patient ate?

Is the patient on any Medications? If so, please list the name, the dosage and the last time it was administered.

DENTAL/SURGICAL RELEASE FORM

I, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above, that I do hereby give EAST HILLS VETERINARY CLINIC DVMs their agents, servants, and/or representatives full and complete authority to perform the surgical procedure described as: Dental Cleaning and Possible Extractions and to perform any other procedure that, at their discretion, may be useful to promote the health of the above described pet, and I do hereby and by the presents forever release the said doctor, their agents, servants, or representatives from any and all liability arising from said surgery on said animal.

I understand that the attending veterinarian will make every effort to contact me regarding treatment in case of unforeseen emergencies.

In the event of an emergency, I select the following resuscitation option:

I give permission for life-sustaining procedures, CPR (Cardio Pulmonary Resuscitation).

I do not give permission for life sustaining procedures, DNR (Do Not Resuscitate)

By signing this consent form, I indicate that I have authorized the described procedures and that any questions I may have were answered to my satisfaction.

Signature

Sign above

I am the owner or agent for the owner of the above described animal and have the authority to execute this consent. I hereby authorize the veterinarians employed by East Hills Veterinary Clinic to perform the following procedure(s), or operation(s): Dental Cleaning and Possible Extractions.

Dental Authorization Form

DENTAL/SURGICAL RELEASE FORM

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