Patient Exam Questionnaire

Name(Required)

First Last

Patient Name(Required)

Procedure Being Performed(Required)

Email(Required)

Best phone number to reach you at(Required)

To your knowledge, has your pet ever experienced complications under anesthesia?(Required)

Yes. My pet has experienced complications under anesthesia

No. My pet has undergone anesthesia without complications

I am unsure whether my pet has experienced complications under anesthesia

My pet has never been under anesthesia

If yes, describe what happened

IF your pet is having a Dental Procedure

Has your pet received previous dental care?

Dental Chews

Teeth Brushing

Dental Cleaning without Extractions *requires anesthesia*

Dental Cleaning with Extractions *requires anesthesia*

None of the Above

During the dental procedure the patient's dental health will be assessed by a thorough dental exam and dental radiographs. It may be deemed necessary for the pet's health and comfort that dental extractions are performed. Do you consent to extractions under veterinarian discretion?

I consent to any recommended extractions.

I would like to be called before any teeth are extracted.

I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. My signature below certifies that I am over eighteen years of age. I have been informed that there are certain risks and complications associated with sedation, anesthesia, and/or any operation/procedure and that the risks/complications have been explained to me. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before the procedure is initiated. I authorize the use of appropriate anesthesia and pain relief medication as needed before, during or after the procedure. I have been informed that there are risks associated with the use of any medication. The nature of these operations or procedures has been explained to me and I understand what will be done. I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. I have been encouraged and given the opportunity to discuss any questions I may have regarding my pet's medical care and my questions have been answered to my satisfaction. I accept that my financial obligations remain regardless of the outcome.

E-signature/Consent(Required)

I have read and understand this authorization and hereby accept and agree to the terms of the consent for treatment.

CPR

In the event that your pet should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of your pet's status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion. Please select your choice below.(Required)

I agree for CPR to be performed in the case of cardiac arrest

I elect a "Do Not Ressucitate" status in the case of cardiac arrest

Sedation/Anesthesia Consent

IF your pet is having a Dental Procedure

CPR

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