Countryside Animal Hospital blue and gold outdoor sign featuring images of dogs and cats.

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Dental and Anesthesia Consent Form

If your pet is scheduled for a dental procedure, please complete this form in advance. It outlines important information about anesthesia, the procedure itself, and your consent for care, so we can ensure a safe, smooth dental visit.

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Dental and Anesthesia Consent Form at Countryside Animal Hospital

Name *

Email *

I, the undersigned owner or authorized agent of the pet named *

Understand and acknowledge that the veterinarians at Countryside Animal Hospital will perform a dental and administer anesthesia as deemed necessary. I understand that some risks always exist with anesthesia and/or dental surgery, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. My signature below is consent to the dental and anesthesia administration.

Risks and Complications:
I am aware that dental surgery and anesthesia carry inherent risks, including but not limited to infection, adverse reactions to medications, bleeding, and the possibility of unforeseen complications.

Pre-Anesthetic Assessment:

I understand that a pre-anesthetic examination will be performed to assess my pet's overall health. However, unforeseen medical conditions or reactions may occur during anesthesia. We recommend having a blood panel run on all pets over the age of 4 to verify they are healthy enough *

Yes, I authorize a blood panel to be run $84
Yes, I authorize a CBC blood panel to be run $48
No, I do not want a blood panel run, and I understand the risks associated with it

During the pre-anesthetic examination the doctor may find a heart murmur. This comes with an increased risk during anesthesia. In this event: *

I understand the risks and would like to proceed with the operation without a blood panel
I authorize a blood panel to test for heart strength $48
I would like to call off the procedure

Dental X-Rays:

Dental X-rays are a critical tool for identifying underlying dental issues that may not be visible during a standard examination. We highly recommend performing dental X-rays to ensure a comprehensive assessment of your pet's dental health. *

Yes, I consent to dental X-rays for my pet $65
No, I decline dental X-rays for my pet at this time

Emergency Procedures:
I authorize the veterinarian to perform emergency procedures or administer additional treatments that may become necessary during the course of the dental. I understand that efforts will be made to contact me in such situations, but if unreachable, I trust the veterinarian's judgment in the best interest of my pet.

IMPORTANT: A phone number that we will be able to reach you on *

be assessment your

Owner's Name: *

Date *

Signature *

Clear Signature

Dental and Anesthesia Consent Form

Dental and Anesthesia Consent Form at Countryside Animal Hospital

Caring for the Pets of Waupaca, Wisconsin, and the Communities Around Us

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