Dental Anesthesia Consent Form Please fill out this form to help us prepare for your pet’s procedure. Client Name(Required) First Last Primary Phone Number(Required)Email(Required) Pet's Name(Required) Today's Procedure(Required) Dental Cleaning Mass Removal Biopsy Stem Cell Harvest Joint Injections Other If other, please specify(Required) Has your pet had any food past midnight last night? Please note, vomiting during and after surgery is very common and if they aspirate food/water they can have severe anesthesia complications, including death.(Required) Yes No Is your pet taking any medication?(Required) Yes No Medication dose and time given(Required) Pre-Anesthetic Bloodwork (Required within 60 days of procedure)Anesthetic episodes carry an inherent risk. Undoubtedly the importance of the procedure outweighs the potential for complications. Pre-anesthetic bloodwork will help minimize the risks during anesthesia and surgery. By testing blood chemistries and hematology values, we can better evaluate the status of your pet's major organ systems.(Required) Yes, I want pre-anesthesia bloodwork, and I accept the additional cost. Bloodwork already completed within 60 days. Initial to confirm(Required) IV FluidsIntravenous catheter placement allows for IV fluid administration during and after surgery to maintain optimal blood pressure. It also allows for the immediate administration of IV emergency drugs should an anesthetic complication arise. Required for any age patient undergoing anesthesia and is included in the Dental surgery package. BiopsyIf a biopsy is being performed, then sending the sample to the lab for histopathology testing will provide important clinical information regarding your pet's health to determine if additional treatment is needed. (Note: This may already be included in your treatment plan.)(Required) Yes, I consent to the biopsy and the associated lab fee. No, I decline the biopsy. Dental RadiographsYour estimate includes dental radiographs. Dental radiographs are performed to determine the status of your pet's oral health in areas that cannot be visualized by the naked eye. Root infections/abscesses and the need to determine if a tooth needs to be extracted can sometimes only be decided with the information provided by dental radiographs. Dental radiographs pose no additional risk to your pet. Teeth ExtractionsMany pets need to have a few teeth removed/extracted along with their teeth cleaning. Your vet may have told you this is required during the consult or that the cleaning/radiographs will be conducted, and then it will be known if teeth need to be extracted. Small rooted teeth such as incisors pose a limited risk for extraction, while canine teeth and pre-molars carry more risk, such as jaw fracture or nerve damage.(Required) I approve dental cleaning and extractions as documented in the treatment plan. I authorize an additional specified amount (specify below) to be spent in addition to the treatment plan for unexpected, recommended extractions while my pet is under anesthesia. Additional Amount Authorized (If you elect $0 and we can not reach you, your pet will be woken up from anesthesia.)(Required) Optional Services That Can Be Performed While Pet SedatedMicrochip permanent identification ($85)(Required) I consent to the placement of a microchip. I decline the placement of a microchip. My pet is already microchipped. Your pet will receive a complimentary pre-anesthesia exam to assess vitals, cardiac, and resp function before anesthesia. If you would like a separate health concern examined, there is a separate examination fee, and the doctor will speak to you regarding the exam findings. ($71)(Required) No, I have no health concerns that I would like examined on my pet. Yes, I would like an exam on my pet (describe concern below). Please describe your concern(Required) Nail trim ($25)(Required) Yes No Ear cleaning ($25)(Required) Yes No Additional services/products (vaccines, professional services, medication/preventative refills, etc.) E-CollarAn e-collar (Elizabethan collar) is recommended for all procedures that involve an incision. It is critical to prevent self-trauma to the incision, which will delay healing and or lead to incision correction surgery. An e-collar has been included with your estimate for surgery. Some owners may prefer an e-collar that fits against the neck (similar to a human neck brace). Please speak to VMC staff if you wish to choose a different e-collar. If you decline an e-collar for your pet's recovery, it is against medical advice, and incision repairs are 100% client financial responsibility.(Required) Yes, I would like an e-collar and I understand the importance of it for my pet's recovery. I decline an e-collar for my pet's recovery and I understand the above risks and responsibilities. I already have an e-collar for my pet. If you already have an e-collar, please bring it with you when you drop your pet off the morning of their procedure. It is very important for us to ensure that the size and fit are appropriate. Chill Pills (Dogs Only)Restricted activity is required for proper healing for 7-10 days. This can be difficult for our young and/or active/energetic canine patients. We have an oral medication that acts as a "chill pill" and helps your pet calmly handle the restricted activity. This can prevent incision complications which may incur additional charges and is very safe for dogs. Our veterinarians will evaluate each pet to ensure this is a safe, suitable option.(Required) No, my pet does not require Chill Pills. Yes, Chill Pills will assist my pet with the recommended activity restriction. I do not have a dog. Anesthesia RiskI, the undersigned owner or agent of the pet identified above, authorize the staff of Veterinary Medical Center of Fort Mill 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. In the event that life saving treatments are needed:(Required) I elect to proceed with life saving treatments. I DO NOT elect to proceed with life saving treatments. Please initial to authorize your selection for life-saving treatment(Required) While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. 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. I have read and fully understand the terms and conditions set forth above.Phone number at which owner can be reached before/after procedure(Required)Alternate phone number at which owner can be reached before/after procedureSignature(Required) Reset signature Signature locked. Reset to sign again Date(Required) MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.