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Fremont Veterinary Clinic
5055 NE Fremont
Portland, OR 97213
DENTAL Authorization & Consent
Owner's Name: Pet's Name:
Address: Species:
Because your pet will have a general anesthetic, the doctors at Fremont Veterinary Clinic recommend that a Pre-Anesthetic Blood screen be performed. This test helps determine if underlying diseases exist which might add risk to your pet's procedure. While this test is required for all cats and dogs over 7 years of age it is helpful for all pets. (Please initial below).
Yes, please perform a Pre-Anesthetic blood Test on my younger pet. ________ (initial)
No, do not perform a Pre-Anesthetic Blood Test on my younger pet. ________ (initial)

I am the owner or agent of the above pet and have the authority to sign this consent. By signing this, I authorize the following procedure(s) on my pet:

 

I authorize the use of appropriate anesthetics and other medications, and I understand that hospital support personnel will be assisting in my pet's care.
I understand that during anesthesia, emergency or unforeseen conditions may make it necessary for the doctor to perform additional or different procedure(s) that are in my pet's best interest. I therefore authorize these emergency procedures until I can be contacted.
I have been advised as to the nature of the procedure(s) and the risks involved. My questions have been answered to my satisfaction and I realize that results cannot be guaranteed. I have read and understand this authorization and consent.

The cost for tooth extraction varies. If dental extractions are necessary due to infection or decay would you like to be contacted? (Please initial below).

No, I do not need to be called before extracting teeth. ________ (initial)
Yes, contact me before any teeth are extracted. ________ (initial)

If we cannot reach you we will proceed with extractions using our best judgment.

Additional Information:

Date
Signature of Owner or Agent
Phone or pager number where you can be reached today. (______)_____________________