Please answer the following questions as they relate to what anesthetics are given to your pet:

    Has your pet ever had a seizure?

    Has your pet ever had trouble with anesthesia?

    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.).

    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 Price Ranges

    All dental packages include the following:

    • Inpatient Exam
    • General Anesthesia
    • Registered Technician Anesthetic Monitoring
    • Dental Prophylaxis
    • Teeth Polishing
    • Intravenous Catheter
    • Fluoride Treatment
    • Fluids during anesthesia
    • Full mouth radiographs
    • Bair Hugger Warming Device
    • Day Hospitalization
    • Toe Nail Trim
    • Ear Check
    • Anal Gland Expression

    I understand the highlighted package is the estimated costs for my pets procedures

    Signature: (sign freehand)

    Date: