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FAMC Dental Anesthesia Consent

* Indicates required field

Client Name *

First

Last

Pet's Name *

Procedure(s) to be performed: *

Is your pet current on vaccines? *

Yes No No, please update today.

Did your pet eat the day of the procedure? *

No Yes

Any vomiting/diarrhea or coughing/sneezing *

No Yes

If yes, please explain: *

Any additional problems or procedures to address today: *

Please list all of your pet's medications, supplements and flea control *

PRE-SURGICAL BLOOD TESTING:
We strongly recommend that all pets undergoing anesthesia have blood work performed prior to any procedure. Blood work helps us to detect infection or anemia and to assess kidney and liver function. Information gained from these lab tests allows us to adjust each patient’s anesthetic protocol as needed. Please select your choice below.

Please select one: *

Routine pre-surgical blood profile (< 7yrs old) $109.00 Senior complete body function profile (>7yrs old) $145.00 I decline any blood work for my pet

DENTAL PROCEDURES:
A treatment plan outlining the expected costs has been provided to me. I understand that the full extent of dental disease cannot be determined until an oral exam and X-rays are performed under anesthesia.

In the event that care beyond the initial treatment plan is needed, please select one of the options below: *

Proceed with any dental surgery/procedures deemed necessary. Note: Cost of dental extractions varies from $16-$214 per tooth plus applicable medications. Please call me before proceeding. I understand that if I am not available by phone, the initial treatment plan will be followed and my pet will be woken up from anesthesia without any additional procedures.

BEST Phone Number *

Alternate Phone Number *

All animals will receive a free nail trim while under anesthesia. If you decline please select below. *

Do NOT trim my pet's nails

If fleas or flea dirt are present on your pet, we will apply a quick acting Capstar flea treatment ($11.50).

I affirm that I am the owner or agent of the animal names above and I am over 18 years of age. My electronic name entry herein constitutes my legal signature and authorizes Fidalgo Animal Medical Center to perform the above procedures. I have been advised of the nature of the services and procedures to be performed, as well as the risks involved. I acknowledge that no guarantee or assurance has been made to me as to the result or cure.

Name *

First

Last

Vehicle make/model/color: *

Phone number for the doctor to call: *

Submit

FIDALGO ANIMAL MEDICAL CENTER

office hours

Monday 7:30 am to 5:30 pm
Tuesday 7:30 am to 5:30 pm
Wednesday 7:30 am to 5:30 pm
Thursday 7:30 am to 5:30 pm
Friday 7:30 am to 5:30 pm
Saturday 7:30 am to 5:30 pm
Sunday CLOSED

Request Appointment

In Case of Emergency

3303 Commercial Ave
Anacortes, WA 98221
FAMC@FIDALGOVETS.COM

Phone: (360) 293-2186

Text: (360) 328-7421

Fax: (360) 293-2187

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