Pet Information

Pet's Name *

Today's procedure is: (example: lump removal, exam, etc.) *

If mass removal(s), confirm location

The last time that my pet had any food before arriving was

My pet is on the following medications

Contact Information

Owner's Name *

First

Last

Email *

Phone *

Note: In case of an emergency and/or prior to additional procedures, you will be contacted by telephone. Please keep yourphone with you.

Additional Phone

In addition to the planned procedure and pre-operative diagnostics, we offer the following options added to your pet’s plan to help ensure safety and comfort (see additional cost).

Electrocardiogram (ECG) reviewed by a cardiologist prior to the procedure:

Pre-anesthetic anti-nausea injection: ask for accurate pricing based on weight

Sanos Dental Sealant

Therapeutic Laser Treatment (speeds healing, reduces inflammation, and decreases pain)

Complimentary Nail Trim

Anal Gland Expression:

Post operative sedatives: ask for accurate pricing based on weight

Dental Procedure Information

It is the recommended standard of care in Veterinary Dentistry that x-rays be taken during dental cleaning procedures. Veterinary Dental Specialists recommend that x-rays be taken of every tooth during every procedure. Studies have shown that 70% of cats and 80% of dogshave some degree of periodontal disease by 2 years of age (varying from inflammation of the gums to loose teeth, gum recession, and infection at the roots of teeth), and up to 40% of cats studied have tooth resorption (tooth resorption results in a hole in the tooth, exposing the nerve and causing pain). Dental x-rays help us find these problems. Often disease conditions will be found that cannot be readily seen without the x-rays. We include dental radiographs on all treatment plans when indicated. A Dental Prophylaxis (dental cleaning) involves ultrasonic scaling of all tooth surfaces including subgingival cleaning where needed. Polishing and application of fluoride is performed after cleaning. After the Dental Prophylaxis, a complete examination of the mouth is performed by the Doctor. During examination the Doctor may find that one or more teeth need to be extracted. This may be due to advanced periodontal disease, fractures of the tooth, resorptive lesions, caries, etc. Extraction of teeth often includes the administration of intraoral nerve blocks. We recommend that you leave the decision to extract teeth up to the Doctor's discretion. But, if you feel that you would rather be informed prior to any extractions we will be happy to contact you. But, PLEASE make sure that you are available at the contact number that you leave with us today. We do not want your pet to be under anesthesia any longer than is necessary.

Please select your choice below

The Doctor may extract teeth if necessary without contacting me (I understand that additional charges will apply. X-rays will be taken if indicated.)
I wish to be contacted before any extractions/treatment, and I will be available by phone at the number(s) that I leave today
I wish to be called, but in the event I am not able to be contacted, I authorize up to $______________ in treatment

CPR Consent: In the event of a catastrophic emergency, please elect what life-saving measures you would like performed so that we may be in accordance with your wishes:(these are at additional cost)

Do NOT perform CPR on my pet
Basic life support and CPR measures (chest compressions, artificial respiration)
Advanced life support and CPR measures (IV medications, fluids, etc)

Please acknowledge the following surgical/anesthesia Information:

I certify that I am the owner, or authorized agent for the owner, of the above pet. I authorize the doctor on duty and assistants to perform the above prescribed procedures including administration ofsedatives and/or anesthetics, as well as any necessary and appropriate medical, surgical, nursing, diagnostic, and/or emergency care for the above pet. I understand that Rancho San Carlos Pet Clinic is not a 24 hour hospital. Should an overnight stay be necessary, direct observation will not be available. If the above pet needs observation we recommend transfer to a 24 hour emergency hospital. All pets undergoing anesthesia at Rancho San Carlos Pet Clinic are required to have pre-anesthetic blood testing to look at basic organ function and to tailor anesthetic medications used. This will also check for pre-existing medical conditions, which may increase the risk of complications during surgery. An intravenous catheter will be placed to provide immediate access to your pet’s circulatory system, this allows for rapid administration of drugs should an emergency situation arise. Your pet’s leg will be shaved to accommodate this procedure. Intravenous fluids are provided to help maintain normal blood pressure,protect vital organs, and maintain proper hydration. All pets undergoing surgery will receive pain injections. Post-operative pain management is a concern with virtually all surgical procedures. Most procedures merit at-home oral medication for several days after surgery and will be dispensed at the veterinarian's discretion. I understand that during these procedures great care is taken to ensure my pet’s health, but unforeseeable conditions may occur that necessitate an extension or variance in the procedure(s) defined above. I authorize Rancho San Carlos Pet Clinic to perform any additional diagnostic, treatment or surgical procedure(s) deemed necessary for medical or surgical complications or any unforeseeable circumstances. I accept responsibility for any result in additional charges. The nature of the procedure and the potential risks have been explained to me and I understand the procedure(s) to be performed. I understand that some risks always exist with anesthesia and/or surgery, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. I will not hold Rancho San Carlos Pet Clinic, the veterinarians, or any team member liable for any complications that may arise. No warranty or guarantee has been stated or implied to me as to the results or cure afforded by these treatments or procedures.My approval of this consent form indicates that any and all my questions have been answered to my satisfaction. I understand that I am assuming full financial responsibility for all services rendered at the time my pet is discharged from the hospital. *

I have read, understand, and authorize

We place the highest priority on ensuring you feel comfortable with the plan for your pet’s care and fully understand the authorizations above before giving your consent. If you have any questions or need clarification on any of the choices, please contact the hospital so a medical team member can review the form with you prior to completing it. As always, thank you for entrusting us with your pet’s care!

Signature of Responsible Party *

Clear Signature

Print name *

First

Last

Date *

Authorization forDental Procedure with Anesthesia Form