Dental Anesthesia Release Form

Name

Phone Number

Pet's Name

Pet's Age

Pet's Sex

MaleFemale

Is your pet on any medications?

YesNo

If yes, please describe

Did your pet have anything to eat/drink after 12am last night?

YesNo

If yes, at what time?

Does your pet have any medical issues we should be aware of?

YesNo

If yes, please specify

Many times, periodontal disease is so severe that teeth must be extracted. In some cases, gum tissue must be removed that may be source of pain for your pet or be creating a pocket for infection. The cost is as follows:

Extraction Grade 1 - $33.00
Extraction Grade 2 - $43.50
Extraction Grade 3 - $93.00
Extraction Grade 4 - $199.50
Dental Radiographs - $179.50 per series (full mouth)

I understand that unlike a person, my pet must undergo anesthesia to determine a treatment plan for extractions and have the option of having the doctor all me before proceeding with treatment.

Please proceed with the following after radiographs:

Please call me prior to proceeding with extractions (I understand that if I cannot be reached the doctor will wait 5 minutes before proceeding with treatments)Please proceed with all recommended extractions/treatments needed for the health of my pet

Should any extractions be performed please see that my pet’s teeth are:

Sent HomeDisposed of

It is understood, for the best interest of my pet, that an IV catheter will be placed for this procedure. (Note: A small area of hair will be clipped on a front leg). Intravenous fluids are given during anesthesia and/or surgery to help maintain blood pressure and allow rapid administration of drugs should an emergency situation develop.

I request that you perform anesthesia on my pet. I understand that there is always a risk for anesthesia. In case of a medical emergency, I authorize and accept financial responsibility for the following type of resuscitation for my pet:

Do not resuscitateCPR Grade 1 (Minimal Attempt; injection) $96.00CPR Grade 2 (Chest Compressions) $239.50CPR Grade 3 (Do all that's necessary, including opening the chest) $529.50

Signature of Owner or Agent (over the age of 18 years old)

Date

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