Anesthesia Dental Consent in Sunnyvale, CA

Name

First Last

Date

Chart #*

Species	Age	Sex	Weight

Phone 1*

Phone 2

Owner Name

First Last

I understand every effort will be made to contact me and if I am unreachable my pet’s services may not be performed/completed in their entirety which could result in repeat visits and additional fees.

Treatment Recommended

When did your pet last eat?*

Is your pet sick?*

What medications is your pet receiving at home?*

Has your pet been scratching, itching or scooting?*

Would you like photo updates?*

We can post pre & post procedure updates to our social media pages so you may view, comment and share.

Please choose and sign one of the 3 options below

I authorize the doctor to perform any and all extractions that are medically necessary, regardless of cost for my pet’s health and I agree to pay any and all costs associated with this service.

I authorize an additional amount in case my pet needs extractions.

Please circle
$550
$900
$1300

I would like the DVM to call me with an estimate. I understand that if the DVM cannot reach me, or has not heard back from me within 10-minutes of a call regarding the need for extractions, my pet will be woken up and will have to be re-anesthetized on the same/or a later day/date at an additional cost.

I certify that I am the legal owner/duly authorized agent for the owner of the animal described above, and do herby authorize Murphy Avenue Pet Clinic to provide care and perform treatment up-to and including diagnostic bloodwork, x-rays, vaccines, medications and administration of medical procedures they consider reasonable and necessary for my animal’s health, safety and comfort. I understand that with any medical procedure there are always risks involved, including death, and that no warranty or guarantee is being made as to the results or cure. I understand additional charges will accrue if my animal is not picked up before the hospital closes on the day he or she is ready to be released from the hospital. I understand payment in full is expected at the time of pick up and I assume full responsibility for all fees associated with the veterinary services provided.

Owner Signature

Owner Type Name