400037 - Marine View Veterinary Hospital

Anesthesia Consent
Client Information
Name *

First Name
Pet's Name *
Email *
example@example.com
Primary Phone Number *
Please enter a valid phone number.
Primary Phone Type *
Alternate Phone Number
Please enter a valid phone number.
Alternate Phone Type
Procedure Information
Date of Procedure

Month Day Year
Date
Reason for Today's Visit *

Dental Prophylaxis Spay Mass Removal Declaw Sedated Exam or Grooming Other
When was your pet last fed? *
Does your pet have any food allergies or dietary restrictions? *

Yes No
Please list food allergies or dietary restrictions. *
Does your pet take any medications? *

Yes No
List all medications your pet takes. Include drug name, strength, and quantity. *
When was your pet was last given medication? *
Anesthesia/Surgery Consent:
As with any medical procedure, anesthesia/surgery is not without risks. Any patient may experience complications, including but not limited to incisional infection, incisional dehiscence, and in rare circumstances even death.

I understand that unforeseen circumstances may necessitate altering care. I assume responsibility for any additional expenses incurred due to this including but not limited to recommended recheck exams, medications, bandaging, radiographs, and additional surgery.

Pre-Anesthetic bloodwork, if not already performed, is required for all patients undergoing anesthesia/sedation to help evaluate organ function prior to the procedure. You will be contacted if concerns arise that would alter the recommended treatment plan prior to the procedure.

I agree to comply with the aftercare instructions and understand failure to do so can increase the risk of post-operative complications.
Life Sustaining Efforts Directive: In the unlikely event of cardiac or respiratory arrest it is our policy to always attempt resuscitation (CPR), unless "Do Not Resuscitate" (DNR) is selected. You will be responsible for the additional costs associated with CPR. Please select CPR or DNR. *

CPR DNR
Would you like to discuss any concerns with the doctor before your pet's procedure today? *

Yes No
Dental Procedures:
If your pet is having a dental procedure today, it is possible that he or she may need oral surgery (extractions) and/or special medical procedures. The cost of this can vary widely depending on the type and extent of the needed work. An accurate estimate can only be generated by the doctor after the radiographs and oral exam is complete and can be provided at your request before proceeding.
Would you like a doctor to call you should your pet need extractions today? *

Yes, call prior to extractions. NOTE: If you are not able to be reached at the provided phone numbers, extractions will not be performed which may necessitate your pet return to have any recommended treatments performed at a later date. No, go forward with any extractions deemed necessary by the doctor at the time of surgery.
Sanos:
Sanos is a dental sealant for dogs that can be applied after a professional dental cleaning to aid in the prevention of periodontal disease for 6 months. It is applied in the gingival sulcus and acts as an invisible barrier to help prevent bacteria from getting under the gumline where it causes periodontal disease. The cost of the product and application is $100.88
For dogs undergoing dental prophylaxis, would you like to have SANOS applied? *

Yes No
Signature of Owner *

Clear
Date *

Month Day Year
Date
Are You A Robot? *
Should be Empty:

Anesthesia Consent

Client Information

Procedure Information

Anesthesia/Surgery Consent:

Dental Procedures:

Sanos: