Antelope Veterinary Clinic Logo
online pharmacy
Please Note: We will be closed on Tuesday, December 31st and Wednesday, January 1st in observance of New years!

Dental And Anesthetic Consent Form

Save time during your next appointment. Complete your dental and anesthetic consent form online from any device at any time before your visit.
Get Started
A smiling gray pit bull dog wearing a blue bandana sits on the floor

Dental And Anesthetic Consent Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pets before your visit.

Please enable JavaScript in your browser to complete this form.

Your pet is undergoing anesthesia today to have a dental cleaning and/or possible extractions to treat or prevent periodontal disease. This procedure may also include preoperative bloodwork, pain management, monitoring, IV fluids, or other procedures as deemed necessary by the veterinarian are to be paid by the owner/agent at the time of service.

Anesthesia inherently has risks. I hereby consent and authorize the above procedures to be performed and understand the risk involved. I understand that during the course of the operation or procedure, unforeseen conditions may occur. These risks increase with your pet’s age and/or if your pet has any concurrent health problems. By signing, you agree that you understand there are inherent risks to anesthesia and that you hold Antelope Veterinary Hospital, its owners, and employees harmless should your pet experience any reactions.

(Initial or write decline)

AUTHORIZATION: I understand that there is always a risk associated with any anesthetic procedure, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The risk increases with your pet’s age and/or if your pet has any concurrent health problems. In the rare case of emergency and I am unable to be reached by the hospital staff, I give Antelope Veterinary Clinic’s veterinarian and staff permission to perform any and all emergency care necessary and understand that additional cost will apply.

(Initial or write decline)

PREOPERATIVE BLOOD WORK: Includes a complete blood count, which evaluates your pet’s red and white blood cells, and a chemistry panel, which assesses electrolytes, kidney function, and liver function. Older animals tend to be at increased risk for complications during anesthesia. A physical exam, regardless of how thorough, frequently cannot detect metabolic issues, such as disease of the liver, kidney, or bone marrow. We recommend preoperative blood work for your pet before he or she undergoes anesthesia and surgery. (Additional fee)

(Initial)

EXTRACTIONS: Extraction (pulling) of diseased teeth may be necessary if there is a loss of healthy attachment to the bone due to advanced periodontal disease. If your pet should need one or more tooth extractions, it is necessary for the attending veterinarian at Antelope Veterinary Clinic to perform the extraction(s). The veterinarian may not have time to reach you prior to extractions as the patient is under anesthesia. If extractions are necessary for the health of your pet, there will be an additional charge.

(Initial or write decline)

INTRAVENOUS FLUIDS: Older dogs (generally over 7 years) and/or sick dogs are better stabilized under anesthesia with IV fluids, which maintains blood pressure and circulation to vital organs. This also applies to healthy dogs undergoing lengthy procedures and dogs that may be pregnant. (Additional fee)

(Initial)

PAIN MEDICATION: Some procedures can be quite painful, and administering pain relief can increase your dog’s comfort level as well as speed the healing process. Your dog’s veterinarian can discuss with you what level of discomfort is anticipated for the procedure your dog is about to undergo.

(Initial)

TREATMENT PLAN: I understand that I have a right to request a treatment plan with an estimated cost for today’s procedure. I further understand that the treatment plan I was provided with is only an estimation and may vary by 20%. I have read and approved the treatment plan given to me for the animal receiving treatment today.

As the owner/agent of the animal receiving treatment today, I certify that I am at least 18 years old and of sound mind to provide consent to today’s procedure. I have had the opportunity to ask all questions that I may have regarding this procedure and understand the risks involved. I further understand that I am responsible for all charges at the time of discharge and that Antelope Vet Clinic does not allow payments or billing. Knowing all of this, I hereby consent to the dental care of my pet on this date.

Clear Signature