Anesthesia 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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Anesthesia Consent Form

Client *

First

Last

Email *

Animal Name

Animal Age

Animal Breed

Consult Date

I may be reached at the following phone number(s):

Contact All Mobiles
Contact All Landlines

discharge. up whatever

I would like to receive text updates:

Preferred time for pick up & review of discharge instructions:

We will call you when {AnimalName} is waking up from anesthesia. (We will call during the procedure if there are significant changes to the plan discussed at the consult. No need to call, please do whatever {AnimalName} needs and let me know after the procedure is finished.)

Time of {AnimalName}'s last meal:

Any coughing/sneezing/vomiting/diarrhea in the past 48h?

Current medications and time(s) last administered:

Anesthetic safety information

Monitoring: We minimize anesthetic risk by monitoring heart rate and rhythm (ECG), respiration rate and quality (ETCO2), body temperature, blood oxygenation (SpO2), and blood pressure throughout the procedure. A technician anesthetist is present throughout the procedure.
IV Catheterization: For procedures requiring general anesthesia, an intravenous catheter is placed to provide us with an easy route to administer medications and fluids (which support blood pressure and kidney function) during the procedure.
Pain Management: We will pro-actively manage pain associated with any oral surgical procedure by administering pain medications before and/or after the procedure, in addition to use of local anesthetics. As with any drug, side effects may be associated with administraion of pain medications and local anesthetic agents.

Authorization for anesthesia and treatment:

I certify that I am the owner of the above-named animal or am responsible for it and have authority to execute this consent. I authorize the performance of the following procedures: Digital imaging, Periodontal Treatment, + #INPUT# , complimentary nail trim at an estimated cost of $.

I authorize the use of such anesthetics as deemed advisable by the Doctor in the performance of these surgical, diagnostic, or therapeutic procedures. I realize that the administration of any anesthetic agent and the performance of any surgical procedure carries a small but realistic possibility of complications, which can include death. Any questions I have regarding these risks have been answered to my satisfaction.

I recognize that unexpected problems may be detected on dental radiographs or examination under anesthesia. In the event that I am not reachable at the number(s) provided, I authorize the Doctor to provide additional treatment, including extraction of teeth, as may be indicated for {AnimalName}'s overall health. I understand that this may incur additional costs beyond the estimate, and agree to pay these additional costs. I understand that payment in full is expected at the time of discharge.

We often use photographs and radiographs in presentations for educational purposes. In addition, we may post images to social media such as Facebook and Instagram. Unless otherwise specified, I authorize the use of photographs of my pet on social media.

I am aware of the nature of the procedures being performed, and I acknowledge that no guarantee has been made as to the results that may be obtained. I understand that my date of birth is required in order to comply with Drug Enforcement Administration reporting requirements for medications dispensed. I am aware that this facility closes at 5:00pm and there is no continuous presence of personnel overnight.

Client's Date of Birth (for DEA):

Signature: *

Clear Signature

Today's Date: *

Anesthesia Consent Form

Anesthesia Consent Form

Anesthesia Consent Form

Anesthetic safety information

Authorization for anesthesia and treatment:

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