Oliver Animal Hospital - DENTISTRY CONSENT FORM

1

Your Name

Your Pet's Name

Email

Phone

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2

I hereby authorize Oliver Animal Hospital Veterinarian(s) to perform the following procedures* This field is requiredCheck all that apply to your pet

Spay

Neuter

Deciduous Tooth (Teeth) Extraction

Dental Cleaning & Associated Dental Treatments

Biopsy

Mass Removal (s)

Laceration Repair

Gastropexy

Cystotomy

Amputation

Ear Hematoma Repair

Hernia Repair

Stenotic Nares Repair

Cruciate Ligament Repair-Dr. Allman

Enucleation

Abdominal Exploratory Surgery

Wound Repair

Esophagostomy Tube Placement

Urethral Cathetrization-Unblock Procedure

Other Procedure (see below)

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3

You chose "other" please type in procedure to be performed below

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4

I understand the following: Should an emergency arise requiring procedures in addition to or different from those now contemplated, I further request and authorize her/him to do whatever she/him deems advisable. * This field is requiredPlease enter your initials here

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5

I consent to the administration and use of anesthesia.* This field is requiredPlease enter your initials here

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6

I agree to pay in full for all the services rendered, including those deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. The nature and purpose of the procedures, possible alternative methods of treatment, risks involved, and possibility of complications, including death, have been fully explained to me. I acknowledge that no guarantee or assurance has been made to the results that may be obtained. Below will serve as your Digital Signature.* This field is requiredPlease enter your initials here

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7

I understand the following statement: OAH require placement of an IV catheter to administer intravenous fluids while under anesthesia. IV fluids will aid the body in stabilizing internal organ function, blood pressure, and aid in metabolizing the anesthesia more efficiently. Along with shaving the hair at the IV catheter site, we may also shave other areas including the surgical site for surgical prepping/cleansing and also the monitor sites so they will function properly.* This field is requiredPlease enter your initials here

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8

I understand the following statement: Your pet will be administered pain management drugs. Pain management drugs will allow your pet to have a more comfortable and faster recovery. We believe controlling our patient's pain is important. For that reason we will administer pain medications before, during and after you pet's medical procedure to control pain, reduce comfort, and promote recovery.* This field is requiredPlease enter your initials here

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9

I understand and agree to the following: All patients admitted for surgery must have a pre-operative blood panel to screen for pre-existing internal organ conditions that may not be evident physically, but could possibly lead to complications. There is and additional charge of $ 63.25 for the perioperative blood panel. Please enter your initials below.* This field is requiredPlease enter your initials here

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10

We offer Home Again Microchip Identification System. This procedure involves a small microchip to be implanted just underneath the skin in between the shoulder blades. With this service we will also mail in your pet's registration. The cost for the microchip placement and mailed in registration is $ 40* This field is required

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11

If your pet is having a DENTAL PROCEDURE performed, PLEASE READ AND INITIAL YOUR CHOICES BELOW* This field is requiredIf further problems are detected while my pet is under anesthesia (check ALL that apply but do not check both the first and second boxes as they contradict one another)

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12

Would you like to be informed when your pet is under anesthesia & we have begun to start their procedure(s)?* This field is required

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13

PLEASE LIST PRIMARY CONTACT NAME BELOW. This will be the first person we contact regarding your pet's medical care.* This field is required

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14

What phone # do you want us to use to contact you?* This field is required

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15

Please list second phone # to contact you* This field is required

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16

If applicable please list a second contact that is able to make medical and financial decisions for your pet if we cannot reach you.* This field is required( Enter Name & Phone # or NA )

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17

If you have a second contact please enter their phone number below* This field is required

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18

I understand the following information: Sometimes surgical or dental procedures require additional unforseen time to complete. You may call to check in on your pet at anytime. It is possible that your pet's pick up time could extend later than normal hospital hours.* This field is requiredPlease enter your initials here

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19

Would you like any other services performed while your pet is with us today?

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20

You can add additional notes regarding your pet below

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