🐾 Dental Anesthesia Release

Please complete this form before your pet’s appointment. Your answers help us provide the best care possible.

Client Name:

Clinic City:

Clinic State:

Clinic Postal Code?

Clinic Phone:

Dental Anesthetic Release/ Extraction Authorization

Current Date:

Client ID:

Client Name:

Patient ID:

Patient Name:

Phone Number(s) where you can be reached at TODAY:

When (Pet Name) was last fed?

Will we be performing any additional procedures today?

Yes

Is your pet on any medication?

Yes

If yes, what?

When were these medications last given?

Does your pet have any of the following problems:

Coughing

Sneezing

Vomiting

Diarrhea

Seizures

Change in appetite or water consumption

{Pet NAME} is scheduled today for a complete oral exam under anesthesia, followed by a dental cleaning, polishing and fluoride treatment. If your pet has not recently had his/her blood panel then a pre-anesthetic blood panel will be performed. This panel will screen the liver and kidneys to evaluate their ability to undergo anesthesia. An IV catheter will be placed, giving us an open and readily available route to deliver medications in case of cardio-respiratory arrest. {NAME} will be receiving IV fluids today; this helps to keep your pet hydrated and maintain normal blood pressure. When pets are anesthetized, it is easier to evaluate any problems not visible during the initial examination allowing us to explore deep into the oral cavity for unerupted teeth, abscessed teeth, infections, and tumors (many of which are highly malignant). If we are unable to contact you at the number(s) given, we will not proceed with the necessary treatment that would be in your pet's best interest.

In addition to the above services your pet may also be sent home with medications as determined by the doctor.

Should dental radiographs indicate necessary extractions, would you like to be contacted by phone prior to the extraction being performed?

I DECLINE any dental extractions without my consent.

Signature

I AUTHORIZE any necessary dental extractions.

Signature

Additional services that you would like your pet to receive:

Ear Cleaning ($49.93)

Anal Gland Expression ($41.95)

Microchip ($65)

Laser Therapy (helps with inflammation and pain) ($60.07)

I, the undersigned owner and designated agent hereby authorize the staff of Cherry Creek Veterinary Hospital to perform a procedure requiring general anesthesia of my animal. I understand that there are potential life threatening risks associated with anesthesia. I understand the veterinarian will make every effort to contact me in the case of unforeseen circumstances regarding treatment of an emergency situation, but if unable to contact me, she/he will proceed with any life sustaining procedures. I am aware of the risk involved and release Cherry Creek Veterinary Hospital from any legal and financial responsibilities arising from anesthetic and surgical complications.

I understand that Cherry Creek Veterinary Hospital does not have 24 hour staffing available and that after clinic hours my pet will be unsupervised.

Signature

Owner or Authorized Agent