Date of Upcoming Procedure(Required)Pet’s Name:(Required)Owner’s Name:(Required) First Last What is your pet’s heartworm prevention medication and when was the most recent dose given?(Required)What is your pet’s flea & tick prevention medication and when was the most recent dose given?(Required)Is your pet on any additional medications or supplements on a regular basis?(Required) Yes No If yes, please describe medication/supplement name, frequency of administration, and most recent dose:(Required)ANESTHESIA EXPLANATIONYour pet will be sedated, then placed under general anesthesia for the procedure using a balanced anesthetic protocol designed for your pet. During anesthesia, your pet will be closely monitored by a qualified veterinary assistant. The heart rate, EKG, respiratory rate, body temperature, oxygen saturation, and depth of anesthesia will be monitored. Where appropriate, a therapy laser treatment will be performed to improve circulation and healing at the surgery site. Post-operative pain control will be provided both in the hospital as well as sent home for continued comfort. The doctor, and/or you, the client, have determined that your pet requires sedation for this procedure. Any use of sedation or anesthesia carries inherent risks. The veterinary staff of Southwoods Animal Hospital will take utmost care to avoid any complications, but such complications cannot always be foreseen. Animals that require frequent sedation for procedures (such as grooming, bathing, etc.) may be required to have periodic blood screenings to confirm kidney and liver health. I understand the risks of sedation and will not hold Southwoods Animal Hospital responsible for unforeseen complications. I authorize Southwoods Animal Hospital and its veterinarians to perform sedation on my pet. Southwoods Animal Hospital provides the following options for pre/post-surgical treatment:Pre-anesthetic blood work**: Complete Blood Count, Chemistry Profile, and Electrolyte testing performed prior to anesthesia to assess your pet's immune system and organ function, and to assist us in choosing anesthetic medications. Recommended for all surgical patients that have not had recent blood work.(Required) Yes No **Requirements: We require bloodwork on procedures for pets that do not have recent bloodwork (within 3 months) with our facility or for those who have a history of abnormalities. If you have a question regarding your pet’s specific situation, please contact us**Home Again Microchip Implant: Microchips are inserted under the skin at the top of the shoulders. Microchips have an individual number that will be registered to you and your pet. All vet clinics and animal shelters have scanners to read these chip numbers, so if your pet becomes missing there is a much higher likelihood that you can be reunited.(Required) Yes No Kindly provide a cell phone number so our team can text you when your pet wakes up from anesthesia:(Required)AUTHORIZATION FOR PROCEDURES/TREATMENTI hereby authorize an anesthetic dental procedure to be performed on my pet, the nature of which has been described to me to my satisfaction and I realize that no guarantee nor warranty can ethically or professionally be made regarding the results or cure.(Required)InitialsI understand that it can be difficult to predict if teeth need extraction when an animal is awake because tartar and movement interfere with the assessment. Severely diseased teeth can cause considerable pain and discomfort and are a source of infections for other organ systems (liver, kidney, lungs, and heart). During the dental cleaning, the teeth are evaluated, and if found to be diseased, they may require an extraction or referral to a veterinary dentist for repair.(Required)InitialsI understand that if a tooth is diseased, extractions may be necessary. Extractions, pain medication, and antibiotics vary in price based on the time required and degree of difficulty. (Required)InitialsI understand that it is necessary to x-ray teeth to evaluate the viability of the root and jaw and that this will be done at the doctor’s discretion at an additional cost.(Required)InitialsWhile performing the dental procedure, should the Dr. find the procedure(s) to be more involved resulting in additional cost above that stated on the estimate show to me, I will be contacted at the phone numbers listed below. If I cannot be contacted, I authorize the doctor to perform the necessary procedure(s).(Required)InitialsI, the undersigned owner, or owner's agent, of the pet identified above, certify that I am at least 18 years of age, and thereby consent to the examination and treatment of my pet by the veterinarians and staff at SWAH, and after consultation with me to prescribe medication for, treat, hospitalize, anesthetize and/or perform an anesthetic dental procedure.(Required)InitialsAnesthesia RisksAnesthesia Risks While I accept that all procedures will be performed to the best of the abilities of the staff at this facility, I understand that veterinary medicine is not an exact science and that no guarantees have been made regarding the outcome of this/these procedures. I have read and understand the nature of the above procedures and accept the specific terms and conditions set forth herein. Should unexpected life-saving emergency care be required I would like the hospital staff to attempt life-saving measures:(Required) Yes No I authorize Southwoods Animal Hospital to do whatever is necessary should an anesthetic complication arise, and I accept responsibility for any additional expenses incurred. Vaccination Requirements:I understand that my pet must be current on vaccinations for canines: DHPP, Bordetella, and Rabies (administered by a licensed veterinarian) and felines: FVRCP and Rabies (administered by a licensed veterinarian) to stay in this facility. If my pet is overdue for these vaccines or if I fail to provide proof of vaccination, they will be administered at my expense. Initial(Required)Fleas & Tick Policy:I understand that if external parasites are found on my pet that an appropriate treatment will be administered at my expense. Initial(Required)I agree that I, or an agent of mine, will pick up my pet and pay for all accrued charges at the time my pet is discharged. Boarding and treatment charges will accrue for each additional day my pet stays in the facility. If I fail to pick up my pet from SWAH within 5 days of receiving written or oral notification given to the contact information on file that my pet is ready to be released, my pet will be considered as abandoned, and SWAH may handle this abandonment in the best interest of the animal and the hospital. Best Contact Number:(Required)Emergency Contact Number:(Required)Name(Required) First Last Signature(Required) Δ
