Owner Name *

First Name

Last Name

Phone *

(###)

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Do you prefer to be reached by call or text? *

Phone Call

Text Message

Either is Fine

Your pet will be undergoing a surgical procedure and general anesthesia today. To identify any underlying abnormalities your pet may have, we recommend pre-anesthetic bloodwork. This bloodwork will check the function of all major organs, evaluate signs of anemia/infection, and determine clotting ability. Knowing these values will help ensure your pet is as healthy and safe as possible for anesthesia. *

Yes, I have read the statement above and would like to proceed with pre-operative bloodwork today.

My pet has had a full comprehensive panel preformed prior to this surgical date (within the last 2 months)

No, I have read the statement above and decline pre-operative bloodwork today and understand the risk involved.

I, the authorized agent of named pet, have been informed that my pet is in need of preventative and/or therapeutic dental care and consent to the appropriate procedures presented by the veterinarians of Goose Creek Pet Hospital. These procedures include but are not limited to the following: dental prophylaxes (scaling/polishing of the teeth), full mouth x-rays, nerve root blocks, antibiotic gel implants, extractions, and gingival flap procedures (the closing of the gap left by extractions). We prefer to give you a call if any additional dental care is needed while your pet is under anesthesia. This call will be made after the scaling and dental exam has been performed. Should any additional procedures be necessary and desirable in the veterinarian’s professional judgement: *

I prefer to be contacted before any additional procedures are performed. If I cannot be reached, I authorize you to proceed with all necessary dental procedures *not to exceed the amount of $400 or _______ above the estimate presented*. I am aware that if the necessary procedure costs exceed this amount, then the procedure will not be performed today and a second procedure will need to be scheduled for a later date.

If I cannot be reached by phone, I do not authorize any unforeseen dental procedures. I am aware that this means affected teeth will be left untreated.

I verify that I am the owner, or authorized agent, of the above-named pet and authorize said procedure to be performed. I authorize the use of anesthesia and other medications deemed necessary by the veterinarian. I have been advised of the nature of this procedure to be performed and the risks involved. I also understand there is always risk associated with any anesthetic procedure, even in apparently healthy pets. I have discussed my concerns with the veterinarian. I hereby consent to, and authorize, the procedure discussed above and any additional procedures necessary in the veterinarian’s professional judgement. I accept full responsibility for all charges. Has your pet ever had any previous reaction or issue with anesthesia/sedation? *

No, my pet has not had any previous reactions to anesthesia to my knowledge.

Yes, my pet has had a previous reaction with anesthesia. I will discuss these conditions with the veterinarian upon arrival.