Client Name *

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Last

Address *

Address Line 1

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Phone *

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Pet's Name *

Breed *

Color *

Age/DOB *

The not Authorization

Sex *

Male
Neutered Male
Female
Spayed Female

I am the owner of the above-described animal and I hereby consent and authorize the performance of a dental cleaning with possible extractions at the discretion of the veterinarian.

IV fluids can help support patients during an anesthetic event. If recommended by the doctor, do you give consent to fluids? Cost is approximately $82

Yes
No

It is our goal to serve you and your pet the best way we know how. The following are suggestions for blood chemistry screening prior to anesthesia. Although we recommend these tests, they are not required unless specified by a doctor.

Animal under 6 years of age, apparently healthy. 6 chemistry screen to assess liver function (ALT, ALKP, TP), Kidney function (BUN, CREA) and blood sugar (GLU). Cost is $62.00
Animal over 6 years of age, or younger with health problems. Complete chemistry panel. In addition to the above tests, Calcium, Phosphorus, Cholesterol, Albumin and Amylase levels are tested. Cost is $90.00
Canine Heartworm and Tick-Borne Disease Test. This tests for heartworm disease as well as 3 tick borne disease including: Lyme, Anaplasmosis and Ehrlichia. Heartworm exams are recommended annually. Cost is $39.90 (Canine Only)
I prefer not to have any blood chemistry test performed.

I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or operation(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedures of operations as are necessary and desirable in the exercise of the veterinarian’s professional judgement.

I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian.

I have been advised as to the nature of the procedures or operations and the risks involved. I realize that results cannot be guaranteed.

Authorization *

I have read and understand this authorization and consent.

Today's Date *

Signature of Owner or Agent *

Clear Signature

Emergency Telephone Number *

Adapted from a form approved by the American Veterinary Medical Association 1982

Dental Anesthesia Release FormEast Emporia Veterinary Clinic

Fill Out the Dental Anesthesia Form

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