Anesthesia, Surgical and Dental Prophylaxis Release Form – Veterinarians in Oviedo, Florida

Name*

First Last

Date*

Email*

Phone*

Patient Name:*

Procedure:*

Additional Emergency Contact Name

First Last

This person is authorized to make medical and financial decisions for this pet regarding this procedure.

Additional Emergency Contact Phone

Want to receive updates during your pet's procedure? Download the TOAH App. Check-in, Chat with us, get medical advice, request medications and appointments, share photos, have virtual visits with our medical team, and much more. Search TOAH on The App Store or Google Play. Be sure to use the same email address that we have on file.

Anesthetic and/or Surgical Procedure*

I authorize the veterinarians and medical team of Tuscawilla Oaks Animal Hospital to examine, perform diagnostics, administer anesthesia, and/or perform surgical procedures as deemed advisable or necessary for my pet's health, well-being, and safety during this procedure(s).
The nature of the specific procedure(s) has been explained to me, and I understand that no guarantee can be made as to the results or outcome. While Tuscawilla Oaks veterinarians and medical team are sure to take all necessary precautions to reduce them, I understand and accept that there are still risks associated with these types of procedures, including the risk of permanent disability or death. I understand and agree that I am financially responsible for the services rendered, including those deemed necessary by the medical team, should unforeseen circumstances arise during the procedure(s).
The treatment plan and all associated charges/fees for this procedure(s) have been discussed, and I understand and consent to proceed. Any estimation of charges/fees for procedures is just an approximation, and the final bill may be less or greater than what is listed on the Treatment Plan.
I have read, understand, and comply with the policies and procedures of this anesthesia and surgical release of Tuscawilla Oaks Animal Hospital and have had all questions or concerns addressed.

I authorize the Tuscawilla Oaks Animal Hospital veterinarians to proceed with all necessary procedures on this date, and no additional contact attempts to me are required.
I authorize the veterinarians of Tuscawilla Oaks to proceed with all necessary procedures on this date up to the dollar amount I authorized on the Treatment Plan. If there is anything additional to the Treatment Plan, please contact me for further authorization.

CPR or DNR*

For every patient in our care, we need to know, in advance, what your wishes are if your pet stops breathing and/or their heart stops beating. We will make every effort to contact you right away should your pet require resuscitative efforts. Please keep in mind, additional costs are incurred with any attempt to resuscitate any patient. Please review and select one option below.

CPR: Cardiopulmonary Resuscitation (CPR): Resuscitative efforts are to be attempted to restore normal heart function and breathing as deemed necessary by the veterinarian(s) until I can be reached. Should my pet require cardiopulmonary resuscitation (CPR), I request that the veterinarian(s) pursue medical intervention as indicated above in the hopes to resuscitate my pet. I understand that there are additional costs and agree to pay the fees associated
DNR: (DNR): No cardiopulmonary resuscitation (CPR) efforts, only the administration of medication to help ease my pet's passing.

Electronic Signature*

I have, read, understand and agree with the choices made above.

Dental Prophylaxis (If not applicable, please leave the "Dental Prophylaxis" section blank.)

If your pet is having a dental prophylaxis today, this includes a complete oral examination, scaling and polishing, and dental radiographs if indicated. These treatments are included on the treatment plan already presented to you. However, in many instances of advanced dental disease (Stage II, III, and IV), we find diseased, loosened, fractured, or mobile teeth upon oral examination; these teeth typically require extraction or other treatments. Unfortunately, the exact number cannot be determined until your pet is under anesthesia. Therefore, we will give you an estimated range based on the severity of your pet's dental disease. If desired, we can contact you during the dental procedure to describe treatments and charges. However, please be aware that this prolongs anesthesia time. If you cannot be reached, your pet will have to be recovered from anesthesia and conclude the procedure at a later date at an additional cost. I have read, understand, and comply with the policies and procedures of this dental prophylaxis release of Tuscawilla Oaks Animal Hospital and have had all questions or concerns addressed.

I authorize the Tuscawilla Oaks Animal Hospital veterinarians to proceed with all necessary procedures on this date, and no additional contact attempts to me are required.
I authorize the veterinarians of Tuscawilla Oaks to proceed with all necessary procedures on this date up to the dollar amount I authorized on the Treatment Plan. If there is anything additional to the Treatment Plan, please contact me for further authorization.

Electronic Signature*

Additional Services

Would you like a home again microchip implant inserted today?*

Home Again Microchip A permanent method of identification. If your pet is lost or stolen, this system can notify you if your pet is picked up anywhere in the country. The tiny microchip is placed under the skin. This service is at an additional cost. Please ask us for more details.

Yes
No
Already has a chip

COLD LASER THERAPY*

Yes, I would like to opt for the cold laser treatment for my pet.
No, I would like to decline this service today.

Cold laser therapy is a drug-free and pain-free option to help decrease inflammation and help with post-surgical recovery. If unsure, a technician will go over all details before leaving your pet in our care.

Consent

I have read and understand the additional services offered to me and the policies and procedures of Tuscawilla Oaks Animal Hospital. I have had any questions or concerns at this time addressed. If not applicable, please leave the "Additional Services" section blank.

Electronic Signature*

Date*