Dental Surgery Consent Form

Name*

First Last

Address*

Street Address Address Line 2 City Province Postal Code

Primary phone #*

Secondary phone #

Email*

Enter Email Confirm Email

Pet's Name*

Phone # where we can definitely reach you today*

This is the number we will call in case of an emergency with your pet, if we require authorization to proceed with additional procedures, or to give you an update. You must answer this number when your pet is in our care.

Age*

Sex*

Female
Spayed Female
Male
Neutered Male

Time of last meal*

: HH

MM

Name and time of administration of pre-visit medications given*

Medications your pet is taking (including natural products and over-the-counter medications)*

Previous issues or concerns with past anesthetics*

No
Yes
Not applicable

Current diet being fed and quantity being fed per day*

Has your pet been fasted for at least 8 hours*

Yes
No

Has there been any coughing, sneezing, vomiting, and/or diarrhea in the past 7 days?*

Does your pet have a history of anxious licking or chewing*

Your pet will have a shaved area where we place the intravenous catheter. If your pet has a history of anxious licking, we will discuss an elizabethan collar to prevent the risk of a skin infection.

Does your pet have any lumps of concern*

Please describe the location and size of the lumps.

Would you like your pet microchipped while under anesthetic?*

Yes
No
Already microchipped

Consent*

The treatment plan and associated costs for this procedure have been reviewed and explained to me in detail.

Consent*

I am aware that pre-anesthetic bloodwork will be performed prior to surgery.

These tests will help us assess the health status of your pet more completely and determine if there are any additional precautions we need to take prior to surgery.

Consent*

We follow a Fear Free protocol that aims at reducing fear, anxiety, and stress in our patients. If we notice that your pet is showing any signs of these, we will automatically administer anti-anxiety/calming medication prior to their sedation. (Please be aware that you are responsible for the cost of this – it varies depending on the weight of the animal)

Consent*

I understand that full mouth radiographs are done with every dental procedure. Once these are completed, we will be contacting you with an estimate if there are concerns that need to be addressed (ie: extractions). Please be advised that we will only hold your pet under anesthesia for 10 MINUTES while we await your response. Please agree to make yourself available by telephone during the day.

Consent

I understand that the practice of veterinary dentistry is not an exact science and that guarantees as to outcome are not possible. I understand that the ultimate success of the proposed treatment may depend on adequate home-care and follow-up and acknowledge my responsibility in this regard.

Consent*

I acknowledge that if I cannot be contacted by phone, additional treatments and extractions will not be performed. I understand my pet may require an additional anesthetic procedure, at an additional cost, at a future date to pursue any additional procedures.

Consent*

I, the undersigned, being 18 years of age or older, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above, that I do hereby give Jackie Gordon DVM, her associate doctors, agents, employees, and/or representatives full and complete authority to perform the surgical procedure described as above.

Consent*

FURTHERMORE, I UNDERSTAND THAT DURING THE PERFORMANCE OF THE PROCEDURE(S) THAT I HAVE AUTHORIZED, UNFORESEEN CONDITIONS MAY ARISE. THEREFORE, I HEREBY CONSENT TO AND AUTHORIZE THE PERFORMANCE OF SUCH PROCEDURES AS ARE DEEMED NECESSARY BY THE VETERINARIAN'S PROFESSIONAL JUDGMENT. I ALSO DO HEREBY ACKNOWLEDGE THAT I UNDERSTAND THAT THERE ARE NO GUARANTEES EITHER EXPRESSED OR IMPLIED THAT THE PROCEDURES AUTHORIZED WILL BE WITHOUT COMPLICATIONS FROM UNEXPECTED EVENTS BEYOND THE VETERINARIAN'S AND HOSPITAL’S CONTROL.

Should my pet have problems under anesthesia I would like:*

CPR initiated (I understand that I will be responsible for the costs of doing so. If CPR initiation is not successful, you are still responsible for the costs.)
No CPR

The risks of surgery and anesthesia have been properly explained to me:*

Yes
No

I would like to speak to the doctor before my pet undergoes anesthetic as I have further questions:*

Yes
No

Do you have pet insurance, if so, what company?*

Please list the insurance policy number.

Signature*

Please print your first and last name in lieu of a signature.

Date*

Monday	8:00am – 5:00pm
Tuesday	8:00am – 5:00pm
Wednesday	8:00am – 5:00pm
Thursday	8:00am – 5:00pm
Friday	8:00am – 5:00pm
Saturday	Closed
Sunday	Closed

HOURS OF OPERATION

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