Dental Consent Form

PLEASE READ AND INITIAL IN FRONT OF EACH APPLICABLE STATEMENT IN THE SPACE PROVIDED

My pet is being admitted for a dental cleaning and/ or comprehensive oral health assessment under general anesthesia, and, in a few cases, for further treatment such as teeth removal. I understand that with dental disease, problems that are present may not be revealed until a thorough exam after cleaning under general anesthesia is performed. These dental procedures require general anesthesia and I understand and accept that there are always inherent risks, including death of the patient.

The following options can help to reduce the risk associated with anesthesia and maximize patient safety. We highly recommend these measures for every patient having a surgical procedure.

Pre-anesthetic blood screen: the risk of anesthetic complications is higher in animals with health problems. We recommend a pre-anesthetic blood screen for every patient having a surgical procedure. This checks for sub-clinical disease (hidden problems) not apparent on physical examination. On the basis of this blood work we can tailor your pet's anesthetic, pain management and recovery protocols to her/his individual needs. The fee for a pre-anesthetic blood screen is $120.00.

Below, please decide whether you would like to authorize pre-anaesthetic blood screen or if you do don't authorize pre-anaesthetic blood screen and accept the inherent associated risks

Below, I will confirm that I understand my pet may have one or more legs shaved in order to place IV fluids

Below, I will confirm whether I authorize the attending doctor to proceed with dental radiographs. or whether I do not authorize any dental radiographs and understand that disease below the gum line involving the tooth roots and all surrounding tissues cannot be fully assessed without radiographs.

In cases where further work of a non-emergency nature (non-life threatening) is required such as teeth removal, selective dental x-rays, etc., every attempt will be made by the doctor to contact the owner to discuss the case. Please be aware that if you decline any needed procedures at this time, or, we are unable to reach you within 5 minutes, your pet would need a second anesthesia at another time in order for those procedures to be performed.

I, the undersigned, owner or responsible party of the admitted patient, hereby authorize the doctors of Edmonton West Animal Hospital & Spay/Neuter Centre (and whomever they may designate as assistants) to administer further work up and treatments as necessary (once the case has been discussed with me, and verbal consent has been obtained) such as teeth removal.

Further, I assume full financial responsibility for all charges incurred to this patient. However, I understand that if efforts to reach me are unsuccessful, and contact cannot be made at the phone numbers provided, no additional work will be performed and may have to be completed at a later date.

If you would like anything additional done at the time of the dental (e.g. lump removal, vaccination, tear duct flushing, etc), please describe in the box below. Additional cost estimates, where applicable, will be provided to you before these services are carried out, and are at the discretion of the attending veterinarian.