Animal Medical Hospital at Glenwood

Dental and General Surgery Consent Form

Complete the dental and general surgery consent form to authorize necessary procedures and ensure safe, professional care for your pet.

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Dental and General Surgery Consent Form

Please carefully read and accurately complete the dental and general surgery consent form to authorize procedure your pet’s procedure.

Date:

Owner's Name: *

First

Last

Owner's Email *

Patient Name: *

Species:

Sex:

Breed:

Age:

Purpose of Hospital Stay:

Dental
Other

Has your pet been fed this morning?

Has your pet received any medications this morning?

General Anesthesia

Authorization your Procedures

Your pet is scheduled for the above procedure, which involves general anesthesia. Although the veterinarians at Animal Medical Hospital at Glenwood utilize very safe anesthetic protocols and monitoring devices, there are inherent risks involved with any patient undergoing anesthesia. An IV catheter will be placed prior to the procedure which will help to facilitate quick administration of emergency medications, if needed.

Pre-Surgical Blood Testing

Many surgeries require pre-surgical blood testing before general anesthesia. In the event that pre-surgical blood testing is optional please indicate below what your preference is for your pet:

Perform a pre-surgical blood screen CBC/Chem10 (recommended if less than 7 years old) - $143.77
Perform a comprehensive pre-surgical blood screen CBC/Chem17 & Electrolytes (Required on pets over 7 years if not done in the last six weeks) - $192.04

Patients Undergoing Dental Procedures

Many times, the teeth and gums need additional treatment which may include extractions, and implanting antibiotics to help with the reattachment of the gums. Cost estimates are available prior to consent.

Please perform additional procedures as needed, with additional cost not to exceed the amount specified below. If needed procedures exceed this amount, please contact me first.
Please do not perform any additional procedures without contacting me first.

Microchip

The cost of a microchip is $97.50 and includes your lifetime registration into the database (done by our office)

Yes, please microchip my pet
No, please do not microchip my pet

While my animal is in the hospital today, I would also like the following:

Refill of the following prescriptions
Purchase flea and tick prevention
Purchase heartworm prevention (provided that there are no missed pills and a current heartworm test)

**Any animal found to have fleas or ticks upon entering the hospital will be treated at owner's expense**

Did you receive an estimate for today’s services? *

Consent For Service *

I hereby authorize the use of such anesthetics you deem advisable for the performance of the above indicated procedures. I understand that the veterinarian does not occupy the building 24 hours a day, but does observe and care for the animals around the clock as needed. I agree to hold you harmless from and against any and all liability arising out of the performance of any procedures referred to above. I also understand that financial payments for said services are due when rendered and that a deposit maybe required at the discretion of hospital administration.

Client's Signature: *

Clear Signature

Emergency Phone: *

Media Authorization *

I grant Animal Medical Hospital at Glenwood permission to capture my pet(s) image and likeness in photographs, video recordings, or any other media format. I grant them permission to copyright, display, publish, distribute, use, modify, print and reprint such images in business materials such as advertisements, brochures, web site images, or other social media.

Date *

Dental and General Surgery Consent Form

Dental and General Surgery Consent Form

General Anesthesia

Pre-Surgical Blood Testing

Patients Undergoing Dental Procedures

Microchip

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