Anesthesia Release Form – Dentistry – Campbell Park Animal Hospital

PETS NAME:*

PROCEDURE:*

The goal of Campbell Park Animal Hospital is to provide the safest surgical/anesthetic experience possible. The more information the doctors have before and during a procedure, the greater the reduction of risk that a problem will occur. Included in your pet's procedure(s) is electronic monitoring, I.V catheter, and I.V fluid administration (at the doctor's discretion). Electronic Monitoring (B.P., Pulse Oximeter, EKG) helps screen for and identify certain cardiac problems, while an IV catheter provides venous access and proper cardiovascular support during anesthesia. IV Fluid administration helps maintain stable blood pressure and keep your pet properly hydrated during the procedure.

Post - operative pain medication will be included as deemed necessary by the veterinarian at an additional cost to ensure your pet's continued comfort after the procedure.

Blood chemistries are recommended to help our doctors screen your pet for potential underlying issues prior to surgery. This panel is performed for an additional cost at a discounted rate.

The following recommendations are in addition to the cost of the surgery:

Blood Chemistry/ CBC $130.00*

I Accept
I Decline

24 Hour PetWatch Microchip $51.00*

I Accept
I Decline

Telephone Number where you can be reached during your pet's visit:*

If you would prefer a TEXT instead of call AFTER your pet's procedure, indicate text number below:

Full Mouth Dental X-Rays*

I accept
I decline

Did you know about 50% of dental diseases are not visible? Teeth can look normal at first glance, but sometimes the only way your Veterinarian can know if your pet is having serious dental issues is by performing full mouth x-rays. Once the problem is identified, the Doctor can treat the problem, thereby relieving your pet's discomfort. Cleaning a pet's teeth without x-rays often results in missed opportunities to improve the quality of life and health of your pet.
Full mouth X-rays $130.00

The teeth cleaning procedure often reveals problems that are otherwise undetected in the awake patient. Therefore, we need a phone number where we can contact you or an individual authorized to make decisions regarding treatment for your pet. Examples of treatment may include: dental X-rays, tooth extraction(s), gum surgery, antibiotic gel treatment ( doxyrobe ), Ora Vet sealer, tumor biopsy, etc.*

YES, contact me at phone number specified above for authorization of recommended treatment(s)
NO need to contact me, I pre-authorize treatment( s ).

* If no contact is made, the patient will not get the necessary treatment.

Sanos™ Veterinary Dental Sealant, when applied to the gum line after a professional dental cleaning, provides 6 months of gingivitis prevention/treatment. Cost range: $35.00 - $100.00*

I Accept:
I Decline:

Consent

I accept all responsibility that my pet is in good health prior to surgery and that all food has been withheld since 8 pm on the night prior to surgery. I am aware of the risk involved and release Campbell Park Animal Hospital and its Staff from any legal and financial responsibilities arising from the procedure. I have read and understand the above recommendations and assume financial responsibility incurred for the procedure(s) and any recommendations chosen.

Owner Signature:*

Date*

Anesthesia Release Form - Dentistry

The following recommendations are in addition to the cost of the surgery:

Contact

Hours