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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
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
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Dental Package Price Ranges K-9 Package A - Preventative only, not to exceed: $385K-9 Package B - Possible extractions, not to exceed: $690K-9 Package C - Multiple extractions, not to exceed: $995K-9 Package D - Severe, multiple extractions, not to exceed: $1450Fel Pkg A - Preventative only, not to exceed: $365Fel Pkg B - Early w/ four or less extractions, not exceed: $740Fel Pkg C - Severe, more than 4 extractions, not to exceed: $900 All dental packages include the following:
I understand the highlighted package is the estimated costs for my pets procedures
Date:
