Dental / General Surgery Consent Form
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1Animal Medical Hospital At Glenwood
Dental / General Surgery Consent Form
Today’s Date: ______/______/______
Client’s Name: ________________________________________________ Pet’s Name: __________________________
Purpose of Hospital Stay:
Dental (
)
Other (
) __________________________________________________
General Anesthesia - Your pet is scheduled for the above procedure which involves general anesthesia. Although the
doctors at Animal Medical Hospital at Glenwood utilize very safe anesthetic protocols and monitoring devices, there are
inherent risks involved with any patient undergoing anesthesia. An IV catheter will be placed prior to the procedure which
will help to facilitate quick administration of emergency medications, if needed.
Pre Surgical Blood Testing - Many surgeries require pre-surgical blood testing before general anesthesia. In the event that
pre-surgical blood testing is optional please indicate below what your preference is for your pet:
(
)
Perform a pre-surgical blood screen (recommended if less than 7 years old) $78.00
(
)
Perform a comprehensive pre-surgery blood screen
$97.00
(Required on pets over 7 years if not done in last six weeks)
Patients Undergoing Dental Procedures -. Many times, the teeth and gums need additional treatment which may include
extractions, and implanting antibiotics to help with the reattachment of the gums. Cost estimates are available prior to
consent.
(
)
Please perform additional procedures as needed, with additional cost not to exceed $ _______. If needed procedures
exceed this amount, please contact me first.
(
)
Please do not perform any additional procedures without contacting me first
Microchip - The cost of a microchip is $69.50 and includes your lifetime registration into the data base which is done by
our office.
(
) Yes, please Microchip my pet
(
) No, please do not Microchip my pet
Morning Feeding - Has your pet been fed this morning? (
) Yes
(
) No
Authorization for Surgery - I hereby authorize the use of such anesthetics you deem advisable for the performance of the
above indicated procedures. I understand that the veterinarian does not occupy the building 24 hours a day, but does observe
and care for the animals around the clock as needed. I agree to hold you harmless from and against any and all liability
arising out of the performance of any procedures referred to above. I also understand that financial payments for said
services are due when rendered.
Clients Signature: ____________________________________________ Emergency Phone #: (_____) ______-______
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