Consent for Anesthesia for Dental/Surgical Form

Please fill out this form as completely and accurately as possible so we can get best prepare for your pets’ procedure.

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EXTRAXTIONS due to

Pet's Name *

First

Last

Anesthetic and Dental/Surgical procedure(s) to be performed

When was the last meal given? *

Please initial here if you do not consent to proceed with life sustaining procedures

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I agree to be responsible for any charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital.

I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital). Any referral or stay at a different facility may results in additional costs that will be the owner’s responsibility.

I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions.

Phone Number *

In case you can not be reached, is there anyone else who may authorize treatment of your pet?

Name *

First

Last

Phone Number *

I have read and fully understand the terms and conditions set forth above, and by signing agree and fully understand all of the procedures and complications that may be involved with my pet undergoing surgery or anesthesia. If I do not receive discharge instructions I have been advised to return immediately.

I agree to terms & conditions.

Name *

First

Last

Signature

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Pre-Dental/Pre-Anesthetic Exam, Testing and Dental Information

Please Read Carefully.

The well-being of your pet is very important to us and our greatest concern. Anesthesia or sedation will be required to perform today’s procedure on your pet.

Prior to the anesthesia/sedation your pet will receive a basic physical exam by our veterinarian. This exam will allow certain medical conditions to be identified that could complicate today’s procedure or other procedures moving forward, and compromise the health of your pet. A physical exam alone may not identify all systemic or metabolic problems that your pet may or may not have. Therefore, we strongly recommend your pet have a pre-anesthetic blood profile performed prior to any anesthetic procedure in order to further evaluate major organ functions. The blood profile will allow us to assess level of hydration, presence of infection, anemia, blood glucose and electrolyte status as well as changes to liver or kidney values, which is important, since these organs are often involved in metabolizing the drugs we use for anesthesia/sedation. By knowing certain parameters we are able to adjust protocols and medications needed to follow the most appropriate and safest anesthetic regime possible. Please be advised that normal results in no way guarantee a successful outcome of the procedure or anesthesia. Chest radiographs and abdominal ultrasound are highly recommended in senior patients >7 years of age. We encourage you to discuss these recommended diagnostics with your veterinarian.

Intravenous catheters and fluids are used for most procedures. IV catheters allow for fluid and drug administration, and give us a direct access to the circulatory system in case emergency drugs need to be administered. IV fluids will aid in maintaining blood pressure and anesthetic recovery. We will need to shave a small amount of fur on the front leg(s) in order to safely place the catheter. Your pet will likely go home with a small bandage on the front or back leg, which will need to be removed once you get home. If this has not been addressed with you, please reach out to the staff prior to leaving.

Your pet will likely receive a combination of injectable and inhalant medications to facilitate optimal levels of anesthesia and to prevent and treat any pain that is present or might arise from the scheduled procedure. We may or may not use an endotracheal (breathing) tube during the procedure. This is used to aid in breathing by delivering oxygen and protects the airway from debris and fluids that might be present in the mouth. There can be a mild cough associated with the placement of a breathing tube up to 48 hours post surgery. If you have further questions please discuss this with the staff.

Your pet will be closely monitored throughout the anesthetic or sedated procedure, by our experienced technical staff, who will use our state of the art equipment to monitor heart rate and rhythm, ECG, breathing rate, oxygen levels, blood pressure, as well as core body temperature. We utilize a circulating warm air system and temperature controlled surgical tables to maintain core body temperature.

Pain prevention and treatment of pain is of utmost importance to us and we utilize multiple modalities to minimize any pain your pet could experience prior to, during and after any surgical or non-surgical procedure.

Initials *

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Dental Information

Your pet will be undergoing a COHAT (Comprehensive Oral Health Assessment and Treatment) today. After your pet is fully anaesthetized and has a breathing tube present to fully protect the airway, the veterinarian will perform a thorough dental/oral exam. Since upward of 50% of periodontal disease can happen under the gum line, we utilize state of the art digital dental radiographs (x-rays) to further evaluate your pet’s teeth. This is very similar to when we go to the dentist. The main difference is that our pets will not sit still long enough and therefore need to be anesthetized. Our experienced veterinary technicians will scale, and polish the teeth using advanced dental equipment. Sometimes teeth can be severely diseased and unsalvageable. In these cases we often recommend extracting the diseased teeth. If any extractions are necessary, we will utilize pain medication and local anesthetic drugs to minimize the post-surgical pain. We often times utilize synthetic bone grafts to fill the dental extraction sites and use absorbable suture material to close the openings left by the extracted teeth. Only veterinarians and registered skilled veterinary technicians under close supervision of the attending veterinarian are legally allowed to extract teeth.

I authorize Jamacha Pet Vets to perform any dental extractions as deemed necessary by the attending veterinarian without any further permission or consent. I have been informed and understand that I will be fully responsible for any additional costs associated with the procedure, which may be outside the original estimate. I further understand that payments are due at the time services are rendered.

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Please DO NOT perform any dental extractions without my permission or consent. I understand that if I cannot be contacted during the time of my pet’s procedure, then NO EXTRAXTIONS will be performed and any additional cost that will be required for any second anesthetic procedure for dental extractions at a later date will be my responsibility.

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To minimize post-dental/surgical bleeding, infection and swelling we recommend not allowing your pet to be active or play with chew toys or other objects that could traumatize any dental extraction sites for a minimum of 7 days. We generally recommend feeding a wet/canned/soft diet after dental procedures.

Additional procedures: Certain procedures are easier to perform when a pet is anesthetized or sedated. Please check any of the following additional procedures you would like to have performed while your pet is anesthetized or sedated. Note that we will only perform these if it is safe to do so. Your pet’s safety is of utmost importance.

Vaccines on request – not recommended – please speak to veterinarian. Price varies per vaccine.

***Note: If there are any lumps/masses that you want removed, please discuss this with the veterinarian in advance. Additional charges will apply.***

Client Signature *

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Date *

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Consent for Anesthesia for Dental/Surgical Form

Pre-Dental/Pre-Anesthetic Exam, Testing and Dental Information

Please Read Carefully.

Dental Information

Jamacha Pet Vets

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