Patient Name *

Client ID# *

Patient Name *

First

Last

If further problems are detected while your pet is under anesthesia, how should they be handled?

Choose ONE of the following: *

Do whatever is needed to give my pet a healthy oral cavity.
Please contact me before proceeding in the event that additional treatment is needed.
Perform only what I have authorized. I understand that additional work will require another anesthetic event to complete treatment.

If I cannot be reached by phone then: *

Perform what is needed.
Perform only what I have authorized.

I have received a treatment plan for treatment *

Yes
No

Phone numbers where I can be reached today:

Cell *

Work

Other

Preferred method of communication: *

Text
Call

I authorize Dr. McCoy and/or Dr. Kocsis, and their designated assistants, to perform the following: *

Comorbidities

Please choose one *

Existing Cardiac Disease
Cardiac Evaluation Recommended
Other
Not applicable

If other, please specify *

Multiple Choice *

I understand that my pet is in a higher anesthetic risk category due to a diagnosed heart condition or murmur. The veterinarian discussed her/his overall health and these risks at length with me.

Multiple Choice *

I understand that complications may arise from this procedure. In the event any medical problems occur, including death, I accept full financial and medical responsibility for my decision and hereby release Lone Star Dentistry & Oral Surgery for Animals, and all of its veterinarians and staff, of all responsibility.

Multiple Choice *

I understand that my pet is in a higher anesthetic risk category due to an ausculted arrhythmia. The veterinarian discussed his/her overall health and these risks at length with me.

Multiple Choice *

I acknowledge that a cardiac evaluation has been recommended for my pet prior to any anesthetic procedure. The risks have been explained to me in detail.

Multiple Choice *

I understand that complications may arise from this procedure including cardiac arrest. In the event any medical problems occur, including death, I accept full financial and medical responsibility for my decision and hereby release Lone Star Dentistry & Oral Surgery for Animals, and all of its veterinarians and staff, of all responsibility and liability for that choice.

A small area on either foreleg may be shaved for placement of an IV catheter.

Should an emergency arise calling for procedures in addition to or different from those authorized, I consent to whatever emergency treatment is necessary. I also consent to the administration of anesthesia. I understand that complications including, but not limited to infection, cardiac arrest, and death could result.

The nature and purpose of these procedures, alternative methods of treatment, risks involved, and possibility of complications have been fully explained to me. I acknowledge that no guarantee or assurance has been made as to the results that may be obtained.

I understand that my veterinarian has referred me to Lone Star Dentistry & Oral Surgery for Animals out of trust and concern that my pet be provided the opportunity to receive advanced veterinary dental care. By signing below, I hereby authorize Dr. McCoy and/or Dr. Kocsis, and their associates, to examine and treat my pet. I agree to maintain my relationship with my regular veterinarian for health issues not related to dentistry. I also assume full financial responsibility for the care of my pet, including for all necessary services rendered for medical or surgical complications and otherwise unforeseen circumstances. I understand that full payment is due at the time of discharge.

Do you give us permission to use photos of your pet on our website and social media channels? *

Yes
No

Owner's Signature *

Date *

Online Forms

Surgery Consent/Release Form