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Patient Name *

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Please read carefully and sign

Your pet is scheduled for a procedure that requires anesthesia. We would like to take this opportunity to recommend preanesthetic testing and explain why it is important to the health of your pet.

Like you, our greatest concern is the wellbeing of your pet. Before placing your pet under anesthesia, a veterinarian will perform a complete physical examination to identify any existing medical conditions that could complicate the procedure and compromise the health of your pet.

Because there is always the possibility a physical exam alone will not identify all of your pet’s health problems, we strongly recommend a pre-anesthetic profile (a combination of blood tests) be performed prior to anesthesia. The tests we recommend are similar to and equally as important as those your own physician would run if you were to undergo anesthesia.

It is important to understand that a pre-anesthetic profile does not guarantee the absence of anesthetic complications. It may however, greatly reduce the risk of complications as well as identify medical conditions that could require medical treatment in the future.

We, therefore, recommend the following additional lab tests (please select one): *

Level I testing: For pets up to five years of age - $94
Level II testing: For pets over five years of age - $137
Pre-anesthetic lab work already performed.
I do not want any additional lab tests for my pet.

Your pet is having a dental cleaning today. The basic service for this procedure includes scaling and removal of plaque and calculus, polishing of enamel, and a fluoride treatment.

***Some dental problems (e.g., fractured teeth, cavity-like lesions, and loose teeth) which require additional treatments or diagnostics (e.g., tooth extraction or radiographs) are not apparent until the pet is under anesthesia.

Should additional treatment or diagnostics be necessary: *

I CONSENT to the treatments or diagnostics and deemed necessary by the veterinarian.
I request to be contacted prior to proceeding.

If I cannot be contacted: *

I AGREE TO ALLOW TREATMENTS/DIAGNOSTICS.
I DECLINE TREATMENT/DIAGNOSTICS AND REALIZE A SECOND ANESTHESIA MAY BE NECESSARY.

Additional Services Available (Please check if desired) *

If none, please initial to confirm: *

I am the owner or agent of the animal described above and have the authority to execute this consent. I hereby consent and authorize the performance of the following procedure(s) and/or operation(s). *

I understand and agree to the above statement.

I understand that during the performance of the forgoing medical procedure(s), unforeseen conditions may be revealed that necessitate an extension of the procedure(s) or different procedure(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarians’ professional judgment. I also authorize the use of appropriate anesthetics, and other medications, and understand that hospital support personnel will be employed as deemed necessary by the veterinarian. I have been advised as to the nature of the procedure(s), the risks involved, possible alternative methods of treatment, and realize that no guarantee nor warranty can ethically or professionally by made regarding the results or cure. *

I understand and agree to the above statement.

Signature of Owner or Agent *

Clear Signature

Date *

Online Forms

Dental/Anesthetic Release Form

Dental/Anesthetic Release Form

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