Gary J. Schwede
Acres North Dental Consent Form Vaccines Current Yes_____ No_____
Admission & Consent for CORE Dental & Anesthesia
Compassionate Care for Pets 5205 13th Street
Lubbock, TX 79416 Phone: 806-793-2863 Fax: 806-792-0801
www.acresnorthvethospital.com
Patient's Name:______________________
Procedure Date:______________________
Owner's Name:_______________________ ____________________________________
Procedure to be Performed: Anesthesia and CORE Dental Procedure
At what phone number(s) may we reach you in case of emergency?____________________________________________________________________ ______________________________________________________________________________
Please list a person and his or her phone number(s) authorized to make decisions on your behalf in case we are unable to reach you at the above phone number(s) in case of emergency:____________________________________________________________________ ______________________________________________________________________________
All dogs must be current on DAPPL4 (distemper/parvo), rabies, bordetella (kennel cough), and CIV H3N2/H3N8 (dog flu) vaccinations within the last year. Dogs must also have had a negative heartworm test and fecal parasite test in the last year, and current on veterinarian prescribed heartworm and flea/tick prevention.
All cats must be current on FVRCP (distemper) and rabies vaccinations within the last year. Cats must also have had a negative FeLV (feline leukemia virus) and FIV (feline immunodeficiency virus) test as well as a negative fecal parasite test in the last year, and current on veterinarian prescribed heartworm and flea/tick prevention.
Has your pet had any food since midnight last night? Your pet is currently eating the following diet:
Yes
No
1
Vaccines Current Yes_____ No_____
Name of Food:_____________________________________________________
How Much?________________________________________________________
How Often?________________________________________________________
Has your pet been coughing, wheezing, or breathing hard? Yes
No
Has your pet been vomiting or having diarrhea?
Yes
No
Does your pet have any allergies?
Yes
No
If yes, please provide more information here:___________________________________
______________________________________________________________________________
Has your pet ever had an adverse reaction to a medication?
Yes
No
If yes, please provide more information here:___________________________________
______________________________________________________________________________
Is your pet taking any medications?
Yes
No
If yes, please list any medications and supplements that your pet is currently taking. Example: Diphenhydramine 25 mg 1 tablet by mouth every 12 hours, last given at 1PM today.
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize the above procedure to be performed by Acres North Veterinary Hospital. I authorize the use of anesthesia and other medication(s) as deemed necessary by the doctor and understand that hospital personnel will be employed in the procedure as directed by the doctor.
Please indicate how would like for us to proceed if extractions or additional procedures are warranted:
_____ I authorize the doctor to proceed with any necessary treatment for your pet, regardless of cost.
_____ I authorize the doctor to proceed with any necessary treatment for your pet up to $___________________. I understand that I will not be contacted unless the total additional cost of necessary services exceeds this amount.
2
Vaccines Current Yes_____ No_____
_____ I do not authorize the doctor to proceed with any additional treatment without my consent. 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(s), which will be at an additional cost to me.
Please initial below:
_____ Please proceed with extreme life-saving measures (CPR). I accept responsibility for all costs incurred.
_____ Please do not proceed with extreme life-saving measures (CPR). I accept responsibility for all costs incurred and understand that withholding extreme life-saving measures could result in my pet's death.
_____ I give consent to allow Acres North Veterinary Hospital to post pictures of my pet on associated social media accounts and website. I understand that this is revocable with my written notification.
_____ I decline the posting of any pictures of my pet to Acres North Veterinary Hospital's social media accounts and website.
If additional space is necessary, please continue on the back and indicate here.
Microchipping is recommended for all pets as a permanent form of identification that will
increase the chances of your pet getting reunited with you if lost. Do you want your pet
microchipped?
Yes
No
Laser therapy is very useful in pain management and helping the healing process in many
disease processes. The Veterinarians at Acres North Veterinary Hospital may recommend laser
therapy to help your pet be more comfortable. Laser therapy is considered an alternative
veterinary treatment to complement conventional veterinary medicine. Do you want to help
reduce pain with a laser therapy session after today's procedure? (prices vary depending on
treatment regimen)
Yes
No
When you take home your pet, please do not let your pet eat or drink excessively the first day home. This is a common mistake and often causes vomiting and/or diarrhea. Wait at least one hour before giving a small portion of food or water. Please call us at (806) 793-2863 with any questions.
Your signature below indicates that you have reviewed this agreement in its entirety and that you agree with the terms for dentistry admission. I affirm that I am at least 18 years of age
3
Vaccines Current Yes_____ No_____ and above the legal age of majority in the state of Texas. If you have any questions about this agreement, please ask a Technician or a Veterinarian. Printed Name:_________________________________________________________________ Signature:_____________________________________________________________________ Date:_________________________________________________________________________ Admit Employee:_______________________________________________________________
4
Vaccines Current Yes_____ No_____
From Acres North For Your Information:
Vaccinations can take up to 10 days in most dogs and cats to be considered protective, and need to be planned for ahead of time to protect your pet from disease and protect all of our boarding guests. Acres North must have proof of vaccinations administered by a licensed veterinarian prior to admission your pet. Acres North does not accept owner-administered vaccinations. If you do not have proof of current vaccinations administered by a veterinarian as listed above, you agree to have Acres North perform an examination (if needed) and administer the necessary vaccinations at time of admission.
Upon arrival, your pet will be visually inspected for signs of fleas, ticks, tapeworms, and other external and internal parasites. If any are found by our Technicians, the Veterinarian will be alerted and an appropriate treatment will be administered at your cost.
Please note:
· For the safety of your pet, pre-anesthesia blood work to screen for hidden illness is performed for all anesthetized or sedated procedures. o Benefits of pre-anesthesia include allowing the doctor to assess your pet's risk group for anesthesia, helps identify hidden pre-existing conditions which have to potential to increase your pet's risks of anesthetic complications, and provides a baseline of information to compare to throughout your pet's life. o If any of the pre-anesthetic blood work results are abnormal, the doctor will discuss any concerning findings with you and may decide to do one of the following: Postpone the anesthesia to a future date; Cancel the anesthesia; Perform additional diagnostic testing to determine a diagnosis; Proceed with anesthesia, but alter the medications and/or procedure(s).
· For the safety of your pet, an IV catheter and peri-operative fluids are administered to support blood pressure and allow access to administer emergency drugs if needed.
· For the safety of your pet, we will closely monitor vital signs and make adjustments as needed, including warming with a heated surgery table, heating pad, and/or warm water blanket, as your pet's condition warrants.
· For the comfort of your pet pain management is given for all dental procedures. If extractions are necessary, pain management medication(s) and antibiotics could be dispensed.
· As a complimentary service to you, we will trim the nails of all patients and express the anal glands of all canine patients while they are under anesthesia.
5
Vaccines Current Yes_____ No_____
I have been advised as to the nature of this procedure to be performed and the risks outlined below:
Abnormal reaction to anesthetic agents, organ failure (heart, liver, kidney, etc.), obstructed airway, regurgitation, aspiration pneumonia, gastric-dilatation volvulus (aka GDV or bloat), nerve damage, post-operative infection, equipment malfunction, and death. Other complications may occur.
No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the doctor. the doctor has provided me with an opportunity to ask questions and receive answers regarding the procedure. This risk includes serious bodily injury or death. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the doctor's professional judgment. I accept responsibility for any result in additional charges.
We may identify additional problems during the dental procedure that could not be identified beforehand, such as broken or abscessed teeth, bone loss, deep pocketing, jaw fractures, etc. These problems are best dealt with while your pet is under anesthesia.
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 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.
I understand no staff will be attending to your pet overnight and that there is the option of transferring to the Small Animal Emergency Clinic located at 6305 66th Street, Ste. 300, Lubbock, TX 79424 (east of Milwaukee Ave. on 66th Street). Their phone number is (806) 797 6483. I understand that Acres North Veterinary Hospital is in no way affiliated with Small Animal Emergency Clinic and that any transfer to Small Animal Emergency Clinic will incur separate charges that I will be responsible for. I also understand I will be responsible for any transportation to and from Small Animal Emergency Clinic.
The staff of Acres North Veterinary Hospital love to share pictures of our guests and patients with the community through social media such as Facebook® and Twitter® and our website. Please help us be involved by letting us post cute pictures of your pets. Like us on Facebook® and follow us on Twitter®.
Pick-ups must occur during normal business hours (Monday Friday 8 AM 12 PM and 2 PM 6 PM and Saturday 8 AM 1 PM) and will be scheduled with you to review necessary aftercare
6
Vaccines Current Yes_____ No_____ and/or medications associated with the procedure. We ask that you arrive at least 15 minutes prior to your scheduled discharge time to allow for check-in. If your travel plans change and you are unable to pick your pet up by end of business on the departure date, you must call us at (806) 793-2863 to discuss accommodations. If there is availability in our boarding facility, we may be able to extend your pet's stay, however if there is not any availability, please make sure you can have your emergency contact or other authorized person available to pick up on your behalf. If Acres North does not hear from you by end of business on the next business day after your scheduled departure date, we will send a letter via certified mail notifying you of the missed departure date. If we have not heard from you by the eleventh day after mailing the letter, your pet will be considered abandoned and we reserve the right to dispose of your pet per Texas Occupations Code, Title 4, Chapter 801, Subchapter H, § 801.357, (a) through (e). You will still remain financially responsible for all additional charges associated with your pet's stay during this time and subject to collections proceedings. I agree to be responsible for all charges incurred while your pet is in the care of Acres North Veterinary Hospital and understand payment is due at the time your pet is released from the hospital. We accept cash, checks (no post-dated checks), CareCredit®, Sunbit®, Scratch Pay®, debit cards, and all major credit cards, including American Express®.
7
Microsoft Word for Office 365