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Pre-Anesthesia Consent Form - Dental Cleaning

Client/Patient Info

Owner's Name (*)

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Email (*)

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Date (mm/dd/yyyy) (*)

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Pet's Name (*)

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Species (*)

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Client Number

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Breed (*)

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Color

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Age

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Consent Info

Like you, our greatest concern is the well being of your pet. Prior to administering anesthesia to your pet, a full physical exam is performed. Included in the price of each dental is: (1) an intravenous catheter and fluid therapy, (2) pain medication before, during, and after the procedure, (3) state of the art anesthesia monitoring and (4) an application of OraVet sealant.

Pre Anesthetic Blood Testing (*)
A blood analysis can reveal underlying problems that may not be outwardly visible. This test provides us with a look at your pet’s vital organ function which can play a critical role in determining how much risk is involved. Before administering any anesthetic, a doctor will evaluate these test results. ($60-114)
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Dental Take Home Kit (*)
After the teeth are cleaned the next step is to slow the return of tartar and plaque. PETS NEED DENTAL CARE TOO. Included in the dental take home package are: 1) T/D treats given twice daily to control tarter. These come in canine, feline, and small bites. The perfect fit for your pet. 2) Aquadent- antiseptic water additive to help control bad breath. This package is discounted $5 if purchased with your dental cleaning. ($28)
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Owner Consent for advanced diagnostics / treatment:
Extractions, antibiotics, radiographs and/pain medications may be required depending on the severity of dental disease. I understand that I am responsible for the cost of these medications administered in the hospital or prescribed for use at home.
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Primary Contact Number (*)

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Alternate Contact Number (*)

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I, the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above and have the authority to execute this consent.

I understand that during the performance of the procedure, an unforeseen situation may arise that necessitates an extension or variance in the procedure set above. I hereby authorize Durango Animal Hospital to use reasonable care and judgment in performing the procedure.

I have been advised as to the nature of the procedures and the risks involved in performing general anesthesia to the above described animal. I realize that results cannot be guaranteed.

I have read and understand this authorization and consent. I further understand that I assume financial responsibility for all services rendered.

By pressing the submit button, I, the owner of the above pet, agree to all of the above statements.