Dental Anesthesia Consent Form

Patient Name*

Species*

Breed*

Sex*

Female Intact

Female Spayed

Male Intact

Male Spayed

Color*

Markings

Date of Birth (or estimate)*

Are vaccinations current?*

Yes

No

Any coughing, vomitting or diarrhea?*

Yes

No

Did your pet eat this morning?*

Yes

No

Has your pet ever had seizures?*

Yes

No

Any illness in the past 30 days?*

Yes

No

***Unless otherwise discussed, all patients will be induced with Propofol and maintained with Isoflurane gas anesthesia. IV catheterization and fluids are mandatory for all anesthetic procedures. Patients will receive pain medication during all procedures. Patients are monitored at all times by our technical staff.

I am the owner/agent of the above-described animal and have the authority to execute this consent and am 18 years of age or older. I hereby authorize the following procedure(s):

PRE-SURGICAL BLOOD TESTING is recommended to help reduce the risk of anesthesia. This tests for organ dysfunction (liver, kidneys), infection, and other systemic diseases (like anemias, etc) that may not be apparent on physical exam.*

Pre-anesthetic panel fee: $72.00 (CBC & Chem-8). Recommended for patients 5 yrs. and younger

Full panel fee: $160.00 (CBC & Chem-14). Recommended for pets older than 5 yrs.

PRE-OP CHEST X-RAYS are recommended to help reduce the risk of anesthesia in older patients and younger animals with signs of cardiopulmonary disease. Recommended for pets aged 7 years and above. The fee for this service is $290.00 with Radiologist Consultation.

DENTAL RADIOGRAPHS may be necessary to evaluate the health of your pet's teeth. The cost of an initial radiograph is $38.00 and additional radiographs are $28.00.

Full Mouth Radiographs $250.00

DENTAL EXTRACTIONS may be necessary for your pet's health. Diseased teeth are painful and pose an increased risk of infection, including tooth root abscesses and infection in other organ systems. Extractions are per tooth and can range from $75.00 to $180.00Selecting this indicates you DO NOT request a phone call for approval of extraction(s) and will assume ALL charges involved.

ICU UNIT An ICU unit provides a heated and oxygenated environment that facilitates your pet's recovery. The fee for this service is $35.00

CERENIA helps to control vomiting during and after surgery. Animals given Cerenia prior to surgery are far less likely to vomit during and after the procedure. Less than 22lb: $80.00, over 22.1lb, by weight.

MASS REMOVAL(S) can be done during dental procedures to avoid additional anesthesia for your pet. If your pet has mass(es) you and your veterinarian have discussed removing prior to this visit, please describe where on your pet they are located.

ADVANCED DIRECTIVE FOR RESUSCITATION To provide the safest anesthesia for your pet, we perform a thorough pre-surgical exam and pre-anesthetic bloodwork (if applicable). During anesthesia, your pet is monitored by trained veterinary staff. Despite all precautions we take, anesthesia is never completely without risk. For this reason, we ask all clients about their wishes regarding CPR. In the event of my pet's heart and/or breathing stops (cardiopulmonary arrest), resuscitation efforts according to the advanced directive authorized below will be undertaken by the doctor(s) and/or staff of Sunridge Animal Hospital. I understand the doctor(s) and/or staff will immediately attempt to contact me via telephone at the numbers provided by me on this form in the event of cardiac and/or respiratory arrest of my pet.

I request the following resuscitation effort to be implemented immediately by the doctor(s) and staff of Sunridge Animal Hospital *

Cardiopulmonary Resuscitation- I request doctor(s) and staff to attempt to resuscitate my pet through the utilization of artificial respiration and/or external chest compressions, as well as the administration of various emergency medications as deemed necessary and appropriate by the attending veterinarian

Do Not Resuscitate- In the event of my pet's cardiac and/or respiratory arrest, I request no person shall attempt to resuscitate my pet and instead attempt to contact me at the number provided.

Do you want an estimate for today's procedure?*

I request an estimate for today's procedure.

I do not request an estimate. I understand that I am responsible for any and all charges accrued during my pet's procedure.