Informed Consent for Anesthesia & Dentistry 

Owner’s Name______________________      Pet__________        Date___________

I, being responsible for the above described animal have the authority to grant you my consent to receive, prescribe for, treat and/or operate upon my pet.

Of course I know there’s some risk:

This form has the simple purpose of making sure you realize that when pets need dentistry, they will need to be under anesthesia, and anesthesia is potentially dangerous.  We, of course will be very careful and attentive to your pet.
I consent to the administration of such anesthesia as may be deemed proper by the doctor.

FASTING:  one of the more common dangers with anesthesia is the possibility of aspiration.  This danger is greatly reduced if your pet has an empty stomach. I assert that my pet has not eaten for at least 7 hours prior to arrival

Also, use this form to consider and check off the choices you need to make prior to anesthesia:

Choosing the appropriate lab work prior to anesthesia:

Basic Blood Screening for kidney disease, liver disease, diabetes, & anemia ($32)

Extensive Blood Screening that also checks for infection, protein levels, electrolytes, and platelet levels ($52)

Doing at least basic blood work prior to anesthesia and dentistry is a major part of making your pet's procedure safe, comfortable, and sucessful.  We will discuss which of these pre-anesthetic lab packages is most appropriate for your pet.

Choosing the appropriate type of anesthesia:

Injectable Anesthesia is less expensive and appropriate for healthy pets that just need a good dental cleaning or minor peridontal work (Usually about $60)

Gas Anesthesia is more appropriate for longer procedures or for high risk breeds, older, weak, or sick patients. (Usually $90-120)

Other things to consider:

IV Fluids, Electronic monitoring, EKG's:  We will discuss whether or not your patient is likely to need any of these things. IV Fluids are $45.  The EKG and electronic monitoring are included when your pet is under gas anesthesia.

Post Dental Laser Therapy really helps reduce post dental gum inflammation and discomfort.  And it speeds the healing process.
Highly recommended. $10

Pain Management is an automatic and included part of our dental procedures.   But, we will probably also recommend some post op pain medications to take home.  This will cost a few dollars.

Post Dental antibiotics:   We usually give an antibiotic injection if your pet's procedure includes extractions or severe peridontal disease.
We may also send home antibiotics to be given at home. The injection is usually $20 and the take home antibiotics if needed are usually $12-20

Other Minor Procedures ... We will gladly do extra things you want done while your pet is under anesthesia such as toe nail trimming, ear cleaning, anal gland expression, wart, cyst, or mole removal, dewclaw removal and so forth.  Usually on a very low or no charge basis

Microchip: It easy to microchip your pet while under anesthesia  ($32 all inclusive)

After carefully reading the above I have signed in agreement.

____________________________________________      Date_____________________________________________

Here's a copy of the consent form you will be asked to sign prior to providing dental services for your pet.  As you will see, it's purpose is simply to make sure you understand that anesthesia is a serious procedure with possible adverse outcomes.  Adverse outcomes that can be minimized. 

One of the most important things we can do to minimize adverse outcomes is to make sure your pet's vital organs are functioning normally prior to anesthesia and this is easily done with fairly inexpensive lab tests.  If, for money reasons, you elect to skip pre-anesthetic blood work you will need to sign this waiver.

This form has some other simple purposes; it helps keep us organized; helps us inform you of optional services, and helps ensure that you're a responsible person.  That responsibility, of course, includes paying your bill.  We have very low prices compared to most vets, but even so, your total bill will usually be somewhere between $150 and $300 depending on the severity of your pet's dental disease and which optional services are needed.  We take our medical services seriously and this form helps.  Thanks