Surgery & Anesthesia Consent FormDate Owner Name:Pet’s Name:Procedure(s):PRE-ANESTHETIC BLOOD SAFETY SCREEN Disorders of the liver, kidneys or blood are NOT detected unless blood testing is done. Abnormalities of any of these may increase the anesthetic risk for your pet. Testing is performed at the clinic immediately prior to anesthesia. Our on-site laboratory lets us screen for hidden problems before your pet’s treatment begins. It can help indicate chemical imbalances that could affect your pet under anesthesia. It is important to understand that a pre-anesthetic profile does not guarantee the absence of anesthetic complications. It may, however, reduce the risk of complications as well as identify medical conditions that could require medical treatment. *We recommend bloodwork for ALL of our patients undergoing anesthesiaPlease initial:Yes, I consent to the recommended bloodwork before surgery. $88I decline the recommended blood work and request that you proceed with the anesthesia.AUTHORIZATION AND CONSENT: I am over the age of 18 years and am the owner of the above-described animal and have the authority to execute this consent. I hereby authorize Wasatch Animal Clinic to perform the mentioned operations, procedures, treatments, examinations, or tests. Wasatch Animal Clinic provides quality anesthesia monitoring and surgical services and will do everything possible to reduce any complications associated with anesthesia and surgery. I recognize that there is some degree of risk, including death, attached to any medical or surgical procedure or treatment. I have discussed any concerns I may have with the veterinarian. I hereby absolve Wasatch Animal Clinic, the veterinarians, staff and this facility from all actions, arising directly or indirectly from the treatment / anesthetic / surgery. Estimates are an approximation of charges to you, and they are based on the anticipated details of services to be performed. Full payment is required upon discharge of your pet. I agree to pay all costs associated with treatment regardless of outcome. In the event of non-payment, I understand and consent to any legal means or action being taken to recover outstanding monies. By signing, I indicate that any questions I have regarding the above-mentioned procedure(s) or treatments(s) have been answered to my satisfaction. I have read and understand this authorization and consent. Owner SignatureDate Phone number where I can be reached during and after surgery: Comprehensive Oral Health Assessment & Treatment(COHAT) Treatment Authorization Wasatch Animal Clinic's COHAT is $350 for dogs and $320 for cats and includes: Pre-surgical Wellness Exam Intravenous Catheter General Anesthesia and Continual Anesthetic Monitoring Comprehensive Oral Exam Dental Radiographic Examination Dental Cleaning (Scaling and Polishing)Pre-Anesthetic Blood Work is optical but recommended in all patients $85 After performing the Comprehensive Oral and Radiographic Exam under anesthesia, the veterinarian will provide a treatment plan unique to each patient depending on the severity and type of dental disease. We encourage you to available by phone during the procedure so we can communicate with you and perform any recommended treatments. Most treatment plans include tooth extractions and home care recommendations. Advanced treatments such as root canal therapy and periodontal surgery may be discussed as treatment options, but are referred to a veterinary dental specialist. Cost of oral surgery and tooth extractions depends on the time spent performing surgery and materials needed.If, in the doctor's professional judgment, teeth should be removed do you give your consent? Please initial next to your choice. Yes, I DO give my consent for the doctors to use their professional judgment and extract any teeth to maintain my pet's health. I do not expect a phone call during treatment and understand the potential cost of oral surgery. I agree to pay all costs associated with treatment. No, I DO NOT give my consent for the doctors to perform recommended extractions. Please call me before any oral surgery to discuss treatment and cost. A treatment plan and estimate will be provided before treatment is performed and after the comprehensive oral and radiographic exam. PhoneIf we cannot reach you, no treatment or extractions will be performed and your pet will require another anesthetic procedure to treat diseased teeth. You will be responsible for the cost of the following procedure.
