ANESTHESIA
CONSENT FORM FOR DENTAL PROCEDURE
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| Your
Name: |
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| Your Pet's Name: |
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| Procedure: |
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| Safety
and Comfort |
| For the
SAFETY and COMFORT of our patients,
and for the peace of mind of our clients,
we have a minimum set of requirements
before, during and after anesthesia.
Additional care above and beyond
our minimum standards for those cases
requiring more is outlined below. The
fees for this care will be fully outlined
in an estimate before services are rendered.
While we attempt to be accurate
it can not include unforeseen circumstances
(all efforts will be made to contact
you if this occurs). |
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OUR
REQUIREMENTS
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For
SAFETY we require the following:
- A pre-surgical
exam (done on the day of surgery)
- A safety catheter
will be placed for intravenous access
for fluids and/or medications
- Advanced monitoring
of vital systems
- Intravenous fluids
administered during surgery to maintain
blood pressure
- Baseline lab
tests of blood within six months
of procedure to determine underlying
problems and metabolism of anesthesia
Advances in
anesthesia and surgery have made most
procedures quite safe, with a low risk
of complications. However, occasional
problems can arise if the veterinarian
is not aware of pre-existing conditions
which may not be evident during the
pre-surgical exam, and diagnostic testing.
We require every pet undergoing general
anesthesia have baseline lab testing
within 6 months of procedure. This
does not guarantee the absence of complications;
however, it will greatly reduce the
risk of complications.
For COMFORT we require the following:
- Post procedure
anti-pain injection
- Pain medication
for home administration
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ADDITIONAL
SERVICES
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| For Additional
Safety we recommend a chest x-ray and
an EKG to check heart size and function. |
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Yes, I would like pre-surgical chest
x-rays. ($155.00)
Yes, I would like a pre-surgical Electrocardiogram
(EKG) ($150.00) |
| For your
convenience we offer the following additional
services. Some are easier and more comfortable
for your pet if performed while under
anesthesia. |
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Yes, I would like a microchip placed
during anesthesia. (52.00)
Yes, I would like a fecal examination
done to check for intestinal parasites.
($23.00)
Yes, I would like the ORAVETTM
Dental Sealant (includes the first OraVet
home kit for continuous protection-a
$26.00 value)- $35.50 |
AUTHORIZATION
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I am the owner or authorized agent
and hereby authorize Midlothian
Animal Clinic (doctors and staff) to
administer treatment and anesthesia
as determined by the attending veterinarian.
Further, I understand why such
diagnostic, medical, and/or surgical
procedures are being performed (their
advantages and possible complications,
as well as possible alternate treatments,
are either made or implied). I
am aware that veterinary monitoring
is not provided overnight. I further
authorize emergency treatment if necessary
without my prior approval. |
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| Date: |
September 7, 2010 |
| Where can we reach
you today? |
(phone number) |
| E-Mail |
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