Pet Information

Pet's Name *

Contact Information

Owner's Name *

First

Last

Email *

Phone *

Additional Phone

Secondary Contact: *

First

Last

* This person has your authority to consent to medical decisions regarding your pet's surgical care in the event we cannot reach you.

Secondary Contact Phone *

Today's procedure is: (example: lump removal, exam, etc.) *

Is your pet currently on medication?

Yes
No

Did your pet receive these medications today?

Yes
No

Please list medication, frequency and dosages if any

When did your pet last receive food? Water?

Pre-Anesthetic Blood Work Release

Your pet is scheduled for an anesthetic procedure. We recommend a comprehensive blood analysis to determine your pet's anesthetic risk criteria. In addition, these results may serve as a baseline for future comparison and evaluation. **If your pet is here through Blue Chip Farm Animal Rescue, these tests ARE NOT paid for by them.

Checkboxes

I-Stat (basic kidney, electrolytes, anemia)
Limited Chemistry (basic kidney, liver and organ function, assists in detection of inflammation, infection, anemia, dehydration etc.
CBC + Extensive Comprehensive Chemistry (kidney function, liver function, electrolytes, assists in detection of inflammation, infection, anemia, dehydration etc.)
I decline the recommended pre-anesthetic blood work at this time and request that you proceed with the anesthesia, although anesthesia risk for my pet has not been determined. I assume full responsibility for this animal.
Recommended pre-anesthetic blood work was performed at a previous appointment within the last 6 months. This blood work was either performed at Creekside Animal Hospital, or a complete copy of the results has been provided today.
Please test my pet for heartworm, lyme disease, ehrlichia and anaplasma today (4DX)

Biopsy Release

If your pet is here for removal of a mass or lump, we recommend submission of the mass for analysis. The cost for this submission should be included in your procedure estimate. If it is not listed, please call the office or ask a staff member at drop off.

Multiple Choice

I approve the recommended biopsy submission
I decline the recommended biopsy submission work at this time and understand that a definitive diagnosis of the mass/lump cannot be given without this test.
Not applicable to my pet.

Anesthetic and Surgery Release

I understand and consent to recommended anesthetic procedures stated above. The nature of such services has been described to me to my satisfaction. I understand that the administration of anesthesia involves some risk to my pet, including rare reactions to medications and death. I authorize Creekside Animal Hospital to perform medical and diagnostic procedures on the animal identified in this record as required for diagnosis and treatment. I understand that all procedures and surgery also involve some risk to my pet. The most common risks include, but are not limited to the following: bleeding, nerve damage, and infection. I also understand that no guarantees or assurances have been made regarding the outcome of this procedure. The doctors and staff of Creekside Animal Hospital will use all reasonable precaution against injury, escape, complications, and death. I agree to not hold the doctor and staff responsible under any circumstances. I understand Creekside Animal Hospital is not a 24-hour facility and is not staffed by medical team after hours. If your pet requires continuous 24-hour care, we recommend transferring your pet to a local Emergency and Specialty facility. I understand that I assume financial responsibility for all services rendered, and that payment is due on the day of service.

In the event that a life threatening emergency should arise, I:

Authorize veterinary staff to perform lifesaving measures.
Prefer veterinary staff not perform lifesaving measures
Not applicable to my pet.

Anesthetic and Surgery Release

I understand and consent to recommended anesthetic procedures stated above. The nature of such services has been described to me to my satisfaction. I understand that the administration of anesthesia involves some risk to my pet, including rare reactions to medications and death. I authorize Creekside Animal Hospital to perform medical and diagnostic procedures on the animal identified in this record as required for diagnosis and treatment. I understand that all procedures and surgery also involve some risk to my pet. The most common risks include, but are not limited to the following: bleeding, nerve damage, and infection. I also understand that no guarantees or assurances have been made regarding the outcome of this procedure. The doctors and staff of Creekside Animal Hospital will use all reasonable precaution against injury, escape, complications, and death. I agree to not hold the doctor and staff responsible under any circumstances. I understand Creekside Animal Hospital is not a 24-hour facility and is not staffed by medical team after hours. If your pet requires continuous 24-hour care, we recommend transferring your pet to a local Emergency and Specialty facility. I understand that I assume financial responsibility for all services rendered, and that payment is due on the day of service. *

I have read, understand, and authorize

This remainder of this form is intended to promote a clearer understanding of the process involved in the dental procedure your pet is undergoing today and to be sure that your wishes are documented regarding extractions. Please be aware of the following facts: A thorough evaluation of your pet's mouth, teeth, and gums cannot be accomplished without the aid of a general anesthetic. Therefore, some findings such as tumors, abscessed tooth roots, periodontal (gum) disease, cracked teeth, or Feline Odontoclastic Resorptive Lesions (a progressive, cavity-like disease in cats) are often found only once a pet is anesthetized, their teeth are probed, and dental x-rays performed (dental x-rays are an essential part of every dental cleaning). It is frequently necessary to change our treatment plan once the pet is anesthetized for this reason which may end up in additional charges not previously anticipated

Certain specialized procedures (i.e. crowns and root canals) are not provided at Creekside Animal Hospital, but are available through board-certified veterinary dentists. These procedures are usually comparable, or more expensive than the same procedures performed on humans due to the use of anesthesia in pets. We can refer you to a board-certified veterinary dental specialist for follow up care, if you so desire.

Certain disease processes are progressive and it is our intent to minimize pain. Therefore, we may elect to perform procedures that will avoid unnecessary pain in the future. (i.e. we may extract a tooth that is not yet loose, but has significant bone loss around it.)

The removal of some teeth may result in unavoidable consequences, such as jaw fractures, or an inability of the pet to keep its tongue in the mouth. If such complications occur, these will result in an additional cost to you.

In order to minimize the time that your pet spends under anesthesia, it is important that we know your desires before proceeding. This avoids delays involved with us trying to contact you to discuss your wishes; or worse yet – us being unable to contact you at all at a crucial decision- making point. During the course of the examination and cleaning, loose or decayed teeth may be found. Unhealthy and decaying teeth can lead to further health complications for your pet including, but not limited to heart disease. Please mark one of the following options indicating your wishes regarding extractions. *

I give my consent for the doctors to use their professional judgment and extract any teeth necessary to maintain my pet’s health without contacting me.
I give my consent for extractions AFTER I have been called and informed of the situation. If I am NOT available, then I DO give my consent for the doctors to extract any teeth necessary.
I give my consent for extractions AFTER I have been called and informed of the situation. If I am NOT available, then I DO NOT consent for the doctors to extract any teeth. I am aware that the doctors believe teeth may need to be removed and that my pet may have to undergo additional anesthesia in the future to have these teeth removed. If this box is checked, then no teeth will be removed without verbal authorization from the owner.

The following people are authorized to make decisions regarding extractions today.

Please list individuals name and phone number in the order in which they should be contacted:

Flea Treatments: I understand that if my pet has evidence of a flea infestation, medication will be given to kill all adult fleas at my cost. *

I understand

Signature of Owner/ Agent *

Clear Signature

Date *

Dental Consent Form