Dentistry & Anesthesia Consent & Admission Form – Acres Animal Hospital

Patient Name*

Scheduled Procedure*

Scheduled Procedure Date*

Pet Owner's Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Admission Information

Does your pet take any medications, drugs, supplements, herbal remedies, vitamins, minerals, etc.? Please list:*

Does your pet have any allergies? Please list:*

Has your pet had any medical problems recently? Please list:*

When was your pet last vaccinated?*

Pet Insurance

Does your pet need a pet insurance claim form? Which pet insurance company?

Anesthesia Information

Your pet will be given several sedative and anesthetic drugs during the course of the surgery.

Has your pet ever had any sedative or anesthetic drugs before?*

Yes
No

Has your pet every had any problems with or complications from sedative or anesthetic drugs before?*

Yes
No

If yes, do you know which drugs?

Has your pet ever had any problems with any other medications or drugs before?*

Yes
No

If yes, please list:

Pre-Anesthetic Bloodwork

Your pet is scheduled for an anesthetic procedure. To help identify problems before they occur, your pet will have blood tests before anesthesia. Dental bloodwork is included in the dental packages because dental disease increases the risk of kidney disease.

Please select your pre-anesthetic bloodwork preference:*

Basic pre-anesthetic bloodtests: Chem10 + Lyte4 blood chemistry panel + CBC (complete blood count) tests included in all dental procedures. If you would like to have additional bloodtesting performed at this time, please indicate below. If your pet is a senior, or has an existing medical condition, then additional tests to check for age related problems, or monitor progression of disease could be done now.

Full pre-anesthetic bloodtests: Chem17 + Lyte4 blood chemistry panel and CBC (complete blood count) tests for seniors or patients with existing medical conditions.

Intraoral Dental X-rays

Intraoral (inside the mouth) dental x-rays can be done to determine the health of the teeth under the gumline and find hidden causes of disease and pain. While all dental patients will have an oral examination while under anesthesia, it is not possible to find or evaluate all types of dental problems visually or with a probe.

Please select:*

Intraoral dental x-rays are required for this procedure and the cost has been included in the estimate.
Intraoral dental x-rays are optional for this procedure, and I authorize intraoral x-rays to be performed.
I decline intraoral x-rays and understand this may cause dental problems to remain undiagnosed & untreated.

Please indicate any additional procedures that you would like done while your pet is anesthetized.

Nail Trim
Ear Cleaning
Anal Gland Expression
Microchipping
Other

If other, please list:

Emergency Contact

Please provide us with any phone numbers where you can be reached during the scheduled procedure:*

Consent

Anesthesia and Surgery Consent*

Consent of Owner or Authorized Agent:

I consent that the services listed above be performed by the staff at Acres Animal Hospital. I understand that some risks always exist with anesthesia and surgery, including a risk of death. Should unexpected lifesaving emergency care be required, Acres staff has my permission to provide this treatment for my pet. I agree to pay for these treatments at the time of discharge from the hospital.

Name of Owner or Authorized Agent*

First Last

Monday	12:00pm – 6:00pm
Tuesday	12:00pm – 6:00pm
Wednesday	12:00pm – 6:00pm
Thursday	12:00pm – 6:00pm
Friday	12:00pm – 6:00pm
Saturday	Closed
Sunday	Closed
Closed Holidays

Online Dental Surgery Consent & Admission Form

Admission Information

Anesthesia Information

Pre-Anesthetic Bloodwork

Intraoral Dental X-rays

Emergency Contact

Consent

Contact Us

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Emergency Info