Oliver Animal Hospital - DENTISTRY CONSENT FORM

1
Your Name
Your Pet's Name
Email
Phone
2
I hereby authorize Oliver Animal Hospital Veterinarian(s) to perform the following procedures* This field is required.Check 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)
3
You chose "other" please type in procedure to be performed below
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 required.Please enter your initials here
5
I consent to the administration and use of anesthesia.* This field is required.Please enter your initials here
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 required.Please enter your initials here
7
I understand the following statement: OAH requires 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 required.Please enter your initials here
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 required.Please enter your initials here
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 required.Please enter your initials here
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.
Yes, I agree to the microchip placement/registration
No, I do not agree to the microchip placement & registration
11
If your pet is having a DENTAL PROCEDURE performed, PLEASE READ AND INITIAL YOUR CHOICES BELOW* This field is required.If 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)
Do whatever is needed to give my pet a healthy oral cavity including, but not limited to tooth extractions
Do only what I have authorized
Please contact me before doing any additional procedures. IF I CANNOT BE REACHED WHILE MY PET IS UNDER ANESTHESIA THEN DO ONLY WHAT I HAVE AUTHORIZED
My pet is not having a dental procedure today
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.
Yes. Text Me
Yes. Call Me
No
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.
14
What phone # do you want us to use to contact you?* This field is required.
15
Please list second phone # to contact you* This field is required.
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 )
17
If you have a second contact please enter their phone number below* This field is required.
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 required.Please enter your initials here
19
Would you like any other services performed while your pet is with us today?
20
You can add additional notes regarding your pet below
Should be Empty: