Dental Anesthesia Release Form – Optional Dental Radiographs

I hereby entrust Beaverton Pet Clinic (BPC) to care for my pet during his/her surgery stay. I am the owner, or a representative of the owner, of the animal presented and have the authority to execute this consent. I have been advised as to the nature of the procedure to be performed and the risks involved. I understand the doctors and staff will use all reasonable precaution against the injury and/or death of my pet, and I hereby consent and authorize this hospital to perform the requested anesthesia and surgical procedures. In the event of unforeseen complications, I give permission to the doctors and staff to take reasonable measures in treating my pet and accept all charges that are incurred as a result of such action. I understand that I must furnish phone number(s) where BPC can reach me or a contact person whom I have authorized to make medical decisions. *

I have read and understand.

DENTAL RADIOGRAPHS

Without dental x-rays, more than 50% of all dental problems in pets will go undiagnosed. For this reason, we recommend dental x-rays for all of our dental patients. Your veterinarian has likely discussed x-rays with you, and the cost has been listed on your estimate and is included in the high-end total. Please select how you would like us to proceed: *

Yes, please proceed with the recommended dental x-rays.
I would like to speak with the doctor. Beaverton will not proceed with x-rays unless my permission is obtained- the doctor can contact me or my agent using the information in the next section. If I am unreachable, please follow the directive below regarding additional treatments.

ADDITIONAL TREATMENT DIRECTIVE

In pets, the teeth cannot be thoroughly studied until the pet is anesthetized. Once under anesthesia, we evaluate each individual tooth and the entire oral cavity for any problems that may need attention. Many pets need some form of additional dental surgery such as extractions. We realize that you may not have planned for these additional services. We must be able to reach you by phone if we find any issues in order to recommend a treatment plan and seek authorization to proceed (cost estimates will be provided). We will make every reasonable attempt to reach you prior to proceeding with any additional services. However, procedures requiring anesthesia are time-sensitive and provide a narrow window of time in which to reach you. *

I have read and understand.

Patient Name *

First

Last

Name of contact person: *

First

Last

This person is: *

Owner
Authorized Agent

Phone Number *

In the event you or your authorized contact person are not reachable, would you prefer us to proceed with any additional recommended treatment? Please select your preference: *

Yes, please proceed with additional treatment. I understand that there will be additional charges for further treatments.
No, please do not proceed with any treatment beyond the initial treatment plan, unless my pet's safety requires it.

E-mail *

Telephone is our primary means of contacting you regarding your pet's procedure, however we sometimes email updated estimates, forms, home care instructions, etc.

BLOOD TESTING

Blood testing is required within the last 2 months for pets 7 years or older, and within the last 6 months for pets under 7 years of age. I understand that blood work is an important aid in determining my pet's health, but does not guarantee a more successful surgery. *If bloodwork is not current, it will be required prior to surgery at an additional fee* *

I have read and understand.

PICKUP AFTER SURGERY

Standard pickup time is usually between 2:00-5:30 pm. We will do our best to accommodate your requested pickup time but due to the nature of hospital operations and anesthesia recovery this may not always be possible. Please provide the earliest and latest times you are able to pick up your pet. *

I have read and understand.

Earliest Time: *

(the earliest available time is 2:00 pm)

Latest Time: *

(the latest available time is 5:30 pm)

Do you have Pet Insurance? *

If yes, do you plan on submitting the final invoice for insurance reimbursement?

I understand that the safety of my pet is the overriding priority. I understand that any price quote I have been given is an estimate and if complications are involved, or the procedure is of greater dimensions than anticipated, the price may be higher. I understand that by signing below, I agree to pay for all charges incurred as such and will pay the balance in full upon discharge of my pet. *

I have read and understand.

Printed Name *

Today's Date *

PRE-ANESTHESIA QUESTIONNAIRE
Please complete no later than 7am on the procedure date

I have been informed of the fasting requirements for anesthesia and will not/have not fed by pet since 11pm the night before surgery: *

Yes
No - if selected, please contact us immediately at 503-646-6101
Other

Is your pet on any medications? *

If yes, please list name of medication(s) and when the last dose was given:

Have you recently applied a topical flea medication to your pet? *

If yes, what date:

Has your pet been ill recently? If so, please describe the symptoms and indicate date/time of last symptoms: *

Does your pet have an ID Microchip? *

Do you have any other questions or concerns for the doctor?

Are there any additional services you would like us to perform while your pet is in the hospital (charges may apply)?

Message