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Dentistry Anesthesia &Procedure Consent Form

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Dentistry Anesthesia and Procedure Consent Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

  • I am the owner or agent for the above-described animal and have authority to execute consent for the surgical/medical procedure known as: A full oral assessment and dental cleaning.
  • The basis for this operation/procedure, its advantages, possible complications, and possible alternative modes of treatment have been discussed with me.
  • I understand that risks and potential complications exist with anesthesia and surgery. These include, but are not limited to: Abnormal reaction to anesthetic agents, organ failure (heart, liver, kidney), obstructed airway, regurgitation, aspiration of vomitus, gastric dilatation-volvulus (GDV), nerve damage, prolonged anesthetic recovery and temporary dysphoria, post-operative infection, equipment malfunction, and death.
  • Specific complications for dentistry include: Oral infections, extraction site dehiscence, bleeding from the mouth, oral pain, corneal ulcers, and mandibular fractures.
  • I understand that further procedures may be therapeutically necessary based on findings during the operation/procedure. I consent to those procedures, their additional cost, and any unexpected lifesaving emergency care deemed necessary by the attending veterinarian.
  • Surgically removed tissues will be processed according to normal hospital policy, to establish an accurate diagnosis.
  • With full understanding of the above, the undersigned owner/agent authorizes my vet to perform, under any anesthetic deemed advisable, said operation/procedure.

I acknowledge and understand that the procedure, its consequences, and subsequent risks have been explained to me, and I have addressed any questions or concerns I may have. I also realize that results cannot be guaranteed.

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