Permission for Anesthetic Dental Procedure and Oral Surgery

Pet Owner / Caretaker on Record(Required)

First Last

Primary Contact Number(Required)

Secondary Contact Number(Required)

Email(Required)

Pet's Name(Required)

Date of Scheduled Procedure(Required)

Procedure: Veterinary Dentistry

Additional Procedures or Concerns (ex. Nail trim, tag and bump removal. If there there are none, please state “none”.)(Required)

I understand and agree to ALL of the following:

My pet will not be fed after 9:00 PM the night before the procedure. My pet may have water until admission. I will give my pet any routine or required medications and I may use a small treat to do this.

Veterinary dentistry is not an exact science. Guarantees of outcome are not possible.

The ultimate success of the proposed treatment may depend on adequate home-care and follow-up visits. I acknowledge my responsibility in this regard. This is particularly so with periodontal disease.

Any anesthetic procedure poses some risk to the patient. I understand that precautions are taken to minimize such risks. In the unlikely event of an anesthetic complication, I authorize Ridglea West Animal Hospital to carry out procedures deemed appropriate for my pet’s wellbeing. I realize that I will be responsible for any resulting charges.

My pet may be photographed for the purpose of documenting the treatment. The photographs may be placed in my pet’s medical file. They may also be used for educational purposes. Confidentiality is assured.

Ridglea West Animal Hospital’s treatment plan includes a good faith estimate of general dental care, possible extractions, and any additional dental procedures. In addition, a charge is included to cover extractions that may result after radiographs. However, the extent of dental care is not fully known until my pet is under anesthesia.

Undetected abnormalities may become apparent during the more detailed oral examination or on the radiographs taken during anesthesia, invalidating the previous estimate. I recognize that additional procedures may be required at a later time.

Therefore, I understand and agree to ONE of the following:(Required)

I authorize treatment as outlined on the estimate given and place no limit on additional charges/services carried out at the doctor's discretion, including but not limited to extractions.

I authorize treatment as outlined on the estimate given and approve charges up to an additional specified dollar amount (specify in the space provided below).

Please call me with a revised estimate before performing any additional procedures not outlined on the estimate given. I understand that my pet will be under anesthesia during this time. If I cannot be reached quickly by phone, I authorize additional treatments deemed appropriate by the veterinarian, including but not limited to extractions.

Please call me with a revised estimate before performing any additional procedures not outlined on the estimate given. I understand that my pet will be under anesthesia during this time. I also understand that if I cannot be reached quickly by phone to approve additional treatments, my pet will receive only the treatments on the signed estimate. The doctors will discuss with me any additional recommendations when I pick up my pet.

I have reviewed the above material. I have had all my questions answered and fully understand the procedures to be performed and the associated risks.(Required)

I acknowledge this requirement.

I understand that Ridglea West Animal Hospital is not staffed overnight.(Required)

I acknowledge this requirement.

Release time for your pet is determined by the number of procedures we have, your pet's recovery, and your pet's procedure. Release time slots are typically scheduled from 4:30-5:10.

Treatment options and procedures have been explained to my satisfaction and I consent to carry out these treatments.(Required)

I acknowledge this requirement.

As the owner or agent of my pet, I hereby give my consent to Ridglea West Animal Hospital to perform the above said procedure(s)(Required)

I acknowledge this requirement.

Signature(Required)

96787

Permission for Anesthetic Dental Procedure and Oral Surgery

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