Patient’s name

Weight

Date

MM slash DD slash YYYY

I am the owner or am responsible of the above named patient. I hereby authorize of the following procedure(s)/surgery:

Estimate acknowledgement

You were provided an estimate for your pet’s procedure today. If optional services are listed on the estimate, please let the front office staff know if you want them performed.

Health History

Did patient eat this morning?

Yes

Any diarrhea or vomiting?

Yes

Any allergies to drugs?

Yes

History of seizures?

Yes

History of heart conditions?

Yes

History of previous surgeries?

Yes

Additional Information about heart conditions

Date

MM slash DD slash YYYY

Previous Surgery History

Previous health history to be noted?

Yes

Date

MM slash DD slash YYYY

Procedure/Health history

On any Medications?

Yes

Name

Last given

How much

How often

Do you need to add Additional Medications

Yes

Name

Last given

How much

How often

Do you need to add Additional Medications

Yes

Name

Last given

How much

How often

Items left with Patient

Elective Procedure

Cerenia ($20-170) [See Below*]

Yes

*Cerenia reduces post anesthetic nausea and contributes to improved recovery and faster return to a normal appetite.*

Pre-anesthetic blood screen ($98) [See Below*]

Yes

*Pre-anesthetic bloodwork is a required safety measure for pets over 7yrs and pets with certain medical conditions.*

Dental Extractions

Dental disease often occurs below the gum line and the extent of the disease may not be detected until your pet is under anesthesia and full mouth radiographs have been performed. If we determine the need for additional procedures, how would you like us to proceed?

Dental Extractions – I

I prefer NPVH to proceed with all procedures regardless of cost past the initial estimate without being contacted first.

Dental Extractions – II

I will be available by phone during my pet’s procedure and request to be contacted with an updated estimate. If I cannot be reached by phone, I authorize the following cost in addition to the initial estimate for further treatment.

Cost

Intravenous Fluids

All animals undergoing anesthesia will receive an intravenous catheter. A small patch of hair will be shaved on your pet’s leg for catheter placement. Intravenous fluids help maintain normal blood pressure during anesthetic which allows all vital organs to receive the blood they require to function properly.

Anesthesia

Most healthy animals tolerate general anesthesia without issue. Those who do suffer side-effects or complications typically have mild, transient symptoms that are easily managed. Anesthesia-related deaths can occur in rare circumstances but your veterinary team will take every precaution during the procedure including close monitoring of your pet’s vital signs. Certain animals have a higher anesthetic risk due to their breed, size, health, or age. Your veterinarian will discuss the appropriate surgical plan based on these factors.

In the event of an emergency, I select the following resuscitation option:

In the event of an emergency, I select the following resuscitation option:

I give permission for life sustaining procedures or CPR (Cardiopulmonary Resuscitation)

I do not give permission for life sustaining procedures or CPR (Cardiopulmonary Resuscitation)

*Additional costs will be incurred in the event of life sustaining procedures*

Owner Release

I have read and understand the nature of the procedure/surgery and the risks involved. I realize results cannot be guaranteed. Advances in anesthesia and surgery have made routine procedures relatively safe with few complications. Nevertheless, problems, even death, can arise due to pre-existing conditions not evident during routine pre-surgical exams.

I agree to be responsible for payment in full of all charges incurred for procedures, treatments, and testing performed on my pet, and acknowledges that payment is due at the time the patient is discharged. I further agree in the case of non-payment, any finance, collection, and/or attorney fees will be paid by me.

Who will be picking pet up

Signature

Date

MM slash DD slash YYYY

Printed Name

Email address for owner

Name and number for contact during patient’s procedure/stay with us

North Pole Veterinary Hospital Dental Admission

Get in touch

(907) 488-2335

Business Hours

(907) 488-2335