Dental Surgery Consent Form

Please fill out ALL fields below before your pet's next dental surgery.

Client (Owner) Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Pet Name*
Breed*
Color*
Age*
Please specify weeks/months/years*
- Weeks
- Months
- Years
Sex*
- Male
- Neutered Male
- Female
- Spayed Female
Consent*
- I consent that my pet has not had anything to eat past 10pm the night before the procedure
Time Pre-visit pharmaceuticals were given (if they were prescribed prior to this appointment)*
Medications my pet is on and last time given*
Previous issues under anesthetic (please elaborate)*
Health concerns the doctor should be aware of (please elaborate)*
Today, my pet also needs:*
- A microchip ($46)
- Vaccinations
- Deworming medication (price is dependant on weight of animal)
- Extraction of retained baby teeth
- DOGS ONLY - Floppy rear dewclaw removal
- None of the above
Please only select the fields below if your pet requires these additional services today. An estimate will be provided for you before we proceed with these additional services.
Consent:*
- I have been offered pre-anesthetic bloodwork: Bloodwork checks kidney and liver enzymes. These blood tests will help us assess the health status of your pet more completely and determine if there are any additional precautions we need to take before surgery.
- I have accepted pre-anesthetic bloodwork.
- I have declined pre-anesthetic bloodwork.
Consent*
- An IV catheter placement is REQUIRED for all anesthetized/surgical patients regardless of age. This placement allows the veterinary staff to administer fluids to maintain hydration and blood pressure. This also allows us quick access to veins in case of an emergency situation. A small patch of fur will be shaved on either the forearm or the back legs in order to do so. This is not optional, it is a required protocol here at Tamarack Veterinary Clinic.
Consent*
- I feel that the risks of surgery and anesthesia have been properly explained to me
- The risks have not been properly explained
Consent*
- I would like to speak to the doctor before my pet goes into surgery as I have further questions
- I have no further questions
Consent*
- We are a Fear Free Certified Clinic that aims in reducing fear, anxiety and stress in our patients. If we notice that your pet is showing any signs of these, we automatically request that your pet receives some anti-anxiety/calming medication prior to their sedation. (Please be aware that you are responsible for the costs of this – it varies depending on weight of animal and breed.)
- I do not consent to Fear Free methods
Consent*
- Full mouth radiographs are done with every dental cleaning. Once these are completed, we will be contacting you with an estimate if there are concerns that need to be addressed (ie: extractions). Please be advised that we will only hold your pet under anesthesia for 15 MINUTES until we await your response. Please agree to make yourself available by telephone during the day.
- Full mouth radiographs: I do not consent
Consent*
- If I cannot be contacted by phone within the timely manner as described above, I authorize any extractions that the veterinarian deems essential.
- I do not consent (please wake my pet up if you don't hear from me within the 15 minutes) - I understand that my pet may require an additional anesthetic procedure, at a significant additional cost, at a future date to pursue any additional procedures.
Consent*
- I, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above, that I do hereby give Suzanne Misiaszek DVM, her associate doctors, agents, employees, students and/ or representatives full and complete authority to perform the surgical procedure described as above
- I do not provide consent to the doctors to perform the procedures as described above
Consent*
- FURTHERMORE, I UNDERSTAND THAT DURING THE PERFORMANCE OF THE PROCEDURE(S) THAT I HAVE AUTHORIZED, UNFORESEEN CONDITIONS MAY ARISE. THEREFORE, I HEREBY CONSENT TO AND AUTHORIZE THE PERFORMANCE OF SUCH PROCEDURES AS ARE NECESSARY IN THE EXERCISE OF THE VETERINARIANS PROFESSIONAL JUDGMENT. I ALSO DO HEREBY ACKNOWLEDGE THAT I UNDERSTAND THAT THERE ARE NO GUARANTEES EITHER EXPRESSED OR IMPLIED THAT THE PROCEDURES AUTHORIZED WILL BE WITHOUT COMPLICATIONS FROM UNEXPECTED EVENTS BEYOND THE VETERINARIANS AND HOSPITAL’S CONTROL.
- I do not consent to the unforeseen risks involved with this procedure
Should my pet have problems under sedation I would like:*
- CPR initiated (I understand that I will be responsible for the costs of doing so. Can range from $300-$600. If CPR initiation is not successful, you are still responsible for the costs.)
- No CPR
Do you have pet insurance, if so, what company & list the policy number?
Signature*
Date*
Date Format: MM slash DD slash YYYY
Best phone number to contact you during the time of appointment*

Have a Question? Need to book an appointment?

Connect with us and one of our team members will be happy to assist you.

CONTACT

2531 – 17th Street NW
Edmonton, AB
T6T 0Y2

Phone: 780-250-1700
Fax: 780-250-1705
Email: info@tamarackvet.com

HOURS

Monday-Friday 8am – 6pm

Closed 12pm-1pm for lunch

Closed Weekends and Holidays

Dental Surgery Consent Form

Have a Question? Need to book an appointment?

Connect with us and one of our team members will be happy to assist you.

CONTACT

2531 – 17th Street NW
Edmonton, AB
T6T 0Y2

Phone: 780-250-1700
Fax: 780-250-1705
Email: info@tamarackvet.com

HOURS

EMERGENCIES

For after-hours please contact either:

Boreal Veterinary Centre
13940 164 St NW, Edmonton, AB T5V 0C8
780-306-4400

Pulse Veterinary Specialists and Emergency
320-450 Ordze Rd Sherwood Park, AB
(780)-570-9999

VCA Guardian Veterinary Emergency and Specialist Centre
5620 99 St NW, Edmonton, AB T6E 1V2
(780) 436-5880

Contact Us

Dental Surgery Consent Form

Have a Question? Need to book an appointment?

Connect with us and one of our team members will be happy to assist you.

CONTACT

2531 – 17th Street NW Edmonton, AB T6T 0Y2

Phone: 780-250-1700 Fax: 780-250-1705 Email: info@tamarackvet.com

HOURS

EMERGENCIES

For after-hours please contact either:

Boreal Veterinary Centre 13940 164 St NW, Edmonton, AB T5V 0C8 780-306-4400

Pulse Veterinary Specialists and Emergency 320-450 Ordze Rd Sherwood Park, AB (780)-570-9999

VCA Guardian Veterinary Emergency and Specialist Centre 5620 99 St NW, Edmonton, AB T6E 1V2 (780) 436-5880

Contact Us

2531 – 17th Street NW
Edmonton, AB
T6T 0Y2

Phone: 780-250-1700
Fax: 780-250-1705
Email: info@tamarackvet.com

Boreal Veterinary Centre
13940 164 St NW, Edmonton, AB T5V 0C8
780-306-4400

Pulse Veterinary Specialists and Emergency
320-450 Ordze Rd Sherwood Park, AB
(780)-570-9999

VCA Guardian Veterinary Emergency and Specialist Centre
5620 99 St NW, Edmonton, AB T6E 1V2
(780) 436-5880