Authorization for Anesthetic Procedure – Dental

Date*
Client's Name*
Patient's Name:*
Primary contact number today*
Secondary contact number today
What is the earliest time you are available to pickup your pet today?*
(Your pet may not be ready to go home by this time.)
Anesthetic and medical or surgical procedure(s) to be performed:*
What other procedures/services do you want performed today?
I, the undersigned owner or agent of the owner of the pet identified above, certify that I am of eighteen years of age or over and authorize the veterinarian(s) at this practice to perform the above procedure(s). I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:
- The reasonable medical and/or surgical treatment options for my pet
- Sufficient details of the procedures to understand what will be performed
- How fully my pet will recover and how long it will take
- The most common and serious complications
- The length and type of follow-up care and home restraint required
- The estimate of the fees for all services
- Any necessary payment arrangements
While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. I agree to pay the estimated fees, assume financial responsibility for the remaining fees, and provide payment in full at the time my pet is discharged from the hospital. Should an unexpected critical situation arise (choose one):*
- I authorize the veterinarian(s) and staff to perform lifesaving procedures and accept financial responsibility for reasonable fees incurred (typically $150-300) in the event I am unable to be contacted.
- I choose that the veterinarian(s) and staff DO NOT resuscitate my pet.
Authorization for Treatment Beyond Estimate (choose one):*
- I authorize any necessary extractions or other treatment beyond the estimate and do not need to be contacted for further consent.
- If extractions or other treatment beyond the estimate is needed and I cannot be reached, I authorize the veterinarian to perform necessary extractions/treatment up to $ ______
- I do not authorize extractions or other treatment beyond the HIGH estimate if I cannot be reached for discussion and understand that the need for a future anesthetic procedure may result.
- I do not authorize extractions or other treatment beyond the LOW estimate if I cannot be reached for discussion and understand that the need for a future anesthetic procedure may result.
$
Microchipping
Microchipping is the most permanent pet identification system available today. Often the best time to place a microchip is when the pet is under anesthesia, so the pet does not have to feel the pain of the larger than average needle.
Would you like to have your pet microchipped during this procedure?*
- Yes
- No
I have read and understand the nature of the above procedures and give my consent to proceed.
Signature*
Date*

Authorization for Anesthetic Procedure – Dental

Microchipping