Animal Medical Care Center 2816 George Washington Memorial Hwy Yorktown, VA 23693 (757) 867-8808 Dentistry Consent Form Please take a moment to read and complete this form so we can give your pet the best possible veterinary care. Pet's Name: _______________________________ Date: ____________________ Procedure to be performed:________________________________ Any special problems you want the doctor to examine:___________________________________________________ Please list the medications your pet is currently taking, the dosage and when they were last given:____________________________________________________________________________________________ When was the last time your pet ate?__________________________________________________________________ Has your pet ever had an adverse reaction to any medication or anesthesia? Yes ( ) No ( ) If yes, please explain:__________________________________________________________________________________________ Class IV laser therapy is the use of a beam of laser light directed into tissues to increase blood flow, reduce pain, decrease inflammation & promote healing from surgical procedures. Would you like your pet to receive laser therapy today for an additional W$e1m5.a0y0 i?denYteifsy(a)ddiNtioon(a)l problems during the dental prophylaxis that could not be appreciated beforehand such as broken or abAscfelsesaed&tteiectkht,rdeaeetmpepnotcwkieltlinbeg,abpopnlie dloasts,thgeroowwtnhesr'isnetxhpeemnsoeuttoh,acnayrpieest,tehtact. tThheevseeteprrinobarleiamnsoarraesbsiessttandteanlottwesitfhlewashoilretyicokusr. pet is under anesthesia. We can contact you with an estimate for treatment before proceeding with additional treatment if indicated. Please indicate below how you would like us to proceed if extractions or additional procedures are warranted: ( ) I WANT the doctor to proceed with any necessary treatment for my pet. I understand that I will be responsible for all charges incurred. ( ) I DO NOT WANT the doctor to proceed with any procedures without my consent. Please call me with an estimate before proceeding with any additional treatment. I understand that if I am unable to be reached by phone, my pet will be recovered from anesthesia, and an additional anesthetic procedure will be needed to correct the problem. ( ) I AUTHORIZE the doctor to proceed with any procedures up to $________________. I understand that I will not be contacted unless the amount of the procedures exceed this amount. I understand that there are certain risks to anesthesia that could involve serious bodily injury or death and that these risks are present in any procedure that requires a general or intravenous anesthetic. This center takes every precaution to ensure the health and safety of your pet. To increase the safety of any procedure involving anesthesia, we require pre-anesthetic blood work in order to determine your pet's physical condition prior to going under anesthesia. I authorize the use of anesthesia on my pet. Initial __________ I acknowledge that changes if my pets condition or discovery of other findings during treatment may necessitate a change in or an extension of the original treatment plan. In the event I cannot be reached, the Animal Medical Care Center has permission to proceed with medical care that will preserve my pet's health or minimize the need for and risks of additional and costly services at a later date. Initial _________ In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and also healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please initial your preference: ________ Please proceed ________ No, please do not _________ Do Not Resuscitate with all life-saving measures. proceed, with any treatment beyond my pet in the event of cardiac and/or I accept responsibility for any non-invasive life support until I can respiratory arrest. costs incurred. be reached. Payment is due and payable upon completion of visit. Cash, Check, or approved credit card. I have read and understand the information printed above. I assume responsibility and understand any remaining balances are to be paid upon the release of my pet. Signature: _______________________________________Date: _________________ Contact Number: _____________________ Thank you for your cooperation in helping us make your pet's stay a safe and happy one!macOS Version 10.14.6 (Build 18G4032) Quartz PDFContext Word