165 Fort Evans Rd. NE, #106
Leesburg, VA 20176
P: 571-209-1146 / F: 571-319-8169
Monday – Friday 8am – 5pm

Consent for anesthesia and dental/oral surgical procedures

I hereby authorize and direct Animal Dentistry & Oral Surgery to perform the procedure(s) and additional diagnostic and/or treatment procedure(s) as deemed advisable or necessary for my pet. The nature and character of the proposed procedure(s) with anticipated results or benefits have been explained to me and no guarantee or warranty has been made as to the results or cure. I realize that during the course of this procedure(s), unforeseen situations may arise. Additional procedures or treatments may be deemed necessary. I understand the extractions(s) or other oral/dental procedures may be indicated and need to be performed. I hereby consent to these additional procedures.

I consent to the administration of general anesthesia to my pet. I understand that all anesthetic protocols and procedures involve some risk to my pet, and that in rare cases may result in potential complications and possible serious damage to critical organs, cardiac arrest, and/or brain death from both known and unknown causes.

I realize that all procedures have basic risks and potential complications. I have been informed and understand that these risks can result in or lead to death or permanent or partial disability, which may be attendant to the performance of any procedure.

If complications arise, transfer to the Critical Care department or other specialist service (for further care) may be undertaken at the doctor’s discretion. I understand and consent to the separate and additional costs associated with the treatment and patient care that may be necessary under unforeseen circumstances.

I understand that AD&OS will not be held liable or responsible in any manner or under circumstances in connection therewith as it is thoroughly understood that I assume all risk and financial responsibility. I understand that any aspect of this consent form that I do not understand can be explained to me in further detail by asking the doctor or an appropriate staff member. I verify that this has been explained to me and that I have read it, understand its contents, and have been afforded the opportunity to ask questions