Like us on
Call us at 916-791-1111
Patient's Name
Your Name
Your Email
Your pet is scheduled for a procedure that requires GENERAL ANESTHESIA today. We are proud of our "safe" anesthesia record here, but we CANNOT GUARANTEE a 100% safe anesthesia every time. We will do everything in our power to ensure a safe anesthesia for your pet.
Please answer the following questions as they relate to what anesthetics are given to your pet:
Has your pet ever had a seizure? YesNo
Has your pet ever had trouble with anesthesia? YesNo
All Hospitalized patients must have proof of a current rabies vaccine.
While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff has my permission to provide such treatment and I agree to pay for such services (Costs can build quickly.). YesNo
Your pet is being admitted for a Comprehensive Oral Health Assessment and Treatment (COHAT). The COHAT includes general anesthesia, whole mouth intraoral radiographs, charting, scaling, polishing, and in some cases nerve blocks and extractions. Our COHAT team involves your pets' veterinarian and registered veterinary technicians (RVTs). RVTs have completed extensive education and training as well as passed a state board exam given by the Veterinary Medical Board of California and are licensed to practice as an RVT. Our veterinarians have completed extra training (beyond veterinary school) in dentistry and oral surgery. Doctors are responsible for completing a physical exam, interpreting pre-anesthetic bloodwork, making an anesthetic plan, interpreting intraoral radiographs, and making a treatment plan which may include extractions and oral surgery. Our RVTs are tasked with anesthetic induction, charting, completing intraoral radiographs, scaling/polishing, nerve blocks and extractions. Our COHAT team's goal is to safely and efficiently improve oral health for all of our patients.
I am the owner or agent for the above pet and have the authority to execute this consent. I hereby consent and authorize Douglas Blvd Veterinary Clinic to perform a Dental cleaning procedure. I understand that during the procedure, unforeseen conditions may be revealed that necessitate an extension of the forgoing procedure. Therefore, I hereby consent to and authorize the performance of such procedures and or surgery as are necessary and desirable in the exercise of the veterinarian's professional judgment. I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed by the veterinarian.
Signature: (sign freehand)
Date: Please leave a number(s) where we can reach you. Sometimes we will find that once we perform a complete dental exam, other issues may arise, such as extractions. WE MAY NEED TO REACH YOU DURING YOUR PET'S ANESTHETIC PROCEDURE, WHERE TIME IS A CONCERN. If we CANNOT reach you, we will proceed with whatever is the best medical interest of your pet and you will be financially responsible. Initial
Phone Number:
Dental package prices vary based on the doctor's evaluation of the pet's oral health. Please contact us for an estimate of the procedure for your pet. All dental packages include the following:
I understand the highlighted package is the estimated costs for my pets procedures
Date:
