Anesthesia/Dental/Surgical Consent Form Client Name* First Last Email* Patient Name:* First Contact Phone Numbers During Surgery* Procedures/Treatments to be Performed:*Please select below any additional services you would like to have performed at this time to reduce the need for future visits and minimize discomfort for your pet. The cost for these services is not included in the cost of the procedure. Please ask our Staff for prices.Additional ServicesNail trimAnal gland expressionEar clean/flushMicrochip placementTooth extractions if necessaryPain medication to take homeStatement of CommitmentThe staff of Central Veterinary Hospital (CVH) assures you that we will use our best judgment in caring for your pet. This judgment is based on experience, the physical exam of your pet, and any laboratory analysis you authorize. Accept Decline Dental & Surgical ReleaseI, the undersigned, do hereby certify that I am the owner or authorized agent of the animal mentioned above. I give CVH full and complete authority to perform the medical and/or surgical procedure and associated anesthesia stated below as well as any procedures deemed necessary by the doctor that are in the best interest of my pet. These procedures may include, but are not limited to, dental radiographs (x-rays), local anesthesia (dental blocks), and extractions of any and all diseased teeth. I understand that in the event that the veterinarian in charge is unable to immediately reach me during the procedure, the procedures will be performed that are in my pet's best interest. I further understand that I will be responsible for all charges for these procedures. I do release CVH from any and all liability for so performing the surgical procedures.Dental RadiographsI understand that full mouth dental radiographs are highly recommended for all patients to examine the health of the teeth and bones below the gum line. I further understand that should I decline full mouth dental radiographs, it may be necessary to radiograph individual areas of the mouth to determine the viability of teeth with questionable or early signs of disease. I understand that the necessity of this procedure will be determined by the veterinarian caring for my pet and agree to be responsible for the charges for these radiographs.Please make one selection: Accept FULL MOUTH radiographs ($100) Decline FULL MOUTH radiographs Dental ExtractionsI understand that dental extractions are often necessary to remove diseased, loose or painful teeth that are revealed during a dental procedure. I understand that these diseased teeth are not always visible on initial or awake examination of a pet and/or may be hidden underneath buildup of plaque, tartar, calculus, or other radiographs. I understand that some extractions may require advanced surgical techniques and agree to the use of these in my pet. I also understand that, due to the position of certain teeth in the jaw, that dental extractions can have inherent risks. These risks include, but are not limited to, infection, nerve damage, hematoma formation (large blood clots forming in the tissue), oronasal fistulas (openings between the nasal passages and the mouth), and fracture of the jaw. I understand that, should any complications occur, the veterinarian in charge of my pet's care will perform the necessary procedures to minimize and/or repair the issue, I understand that, should the veterinarian in charge of my pet's care be unable or immediately reach me during the procedure , that they will proceed with the care that is in the best interest of my pet, I agree to be responsible for the charges associated with the care and release CVH from any and all liability for so performing any of these procedures.Intravenous Fluids, Flea Medications, and Pain MedicationsI understand that my pet will receive intravenous fluid therapy in conjunction with their anesthetic procedure today. I understand that this requires placement of an intravenous catheter, a minor procedure that will require shaving of one or more legs. Although we choose anesthetics we feel to be the safest in each case, IV fluids help improve the safety of certain surgical events. In addition, IV fluids can help speed a pet's recovery from anesthesia and help our pain control medications work more effectively. I understand that if my pet is discovered to be carrying fleas or other external parasites, he or she will be treated appropriately for such at my expense. I understand that pain control medications will be given in hospital and prescribed for post-surgical use at the doctor's discretion.Payment PolicyI agree to pay, in full, for services rendered including those deemed necessary for medical or surgical complications or otherwise unforseen circumstances. I understand that any provided estimate of fees for presently planned procedures is only a best approximation, and the the final bill may be less or greater than this estimated amount. Should I fail to pay for any services provided, I will be responsible for all service charges and collection fees.Pre-Anesthetic BloodworkMany health problems cannot be identified by a physical exam, therefore we do require, at the Veterinarian's discretion that all pets receive a preanesthetic blood screen to help determine the presence of internal illness that may cause complications with anesthesia. This screening does not guarantee the absence of potential complications, but does greatly reduce the risk of complications and helps identify health conditions that may require medical treatment in the future. The cost of the preanesthetic panel and CBC is $70. Please initial the box that you understand the required blood work.Resuscitation StatusI understand that the doctors and staff of CVH will take all reasonable precautions to ensure the safety of my pet but that adverse events, up to and including death, are possible with anesthesia. In the case that my pet goes into cardiac arrest while under the care of CVH, I approve the use of all reasonable measures to resuscitate my pet. These may include, but are not limited to, CPR, injectable medications, and oral/parenteral medications. I understand that the doctors of CVH will determine what measures are reasonable and at what point such measures should be discontinued. I agree to be held responsible for the costs associated with any resuscitation attempt that is made on my pet. Signature*Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.