Pre-Surgical Dental Consent Form

Name

First Last

Pet Name

Breed

Pet Birthday

List any known allergies this pet has

Phone

Alternate Phone

Current medications and time of last dose

Has this veterinarian previously examined this pet?

I fully understand the procedure my pet is here for today

Were you given an estimate of the costs for today's surgery/procedure?

Would you like an estimate now?

Has this pet eaten today?

Vaccines

Charges for vaccines are: $28.00 per vaccine, plus examination fee. Except feline leukemia vaccines which are $31.50 and influenza which are $42.50.
It is our clinic policy to require up-to-date vaccinations on all pets entering our hospital for surgery, grooming and day boarding.
Required vaccines are:
DOGS:
• Distemper (DALPP)
• Rabies
• Bordetella (ITT)
CATS:
• Distemper (FVRCPC)
• Rabies
FERRETS:
• Rabies

Pre-Anesthetic Blood Testing

Additional cost of $78.44

Like you, our greatest concern is the well being of your pet. Before anesthetizing your pet, the veterinarian will perform a full physical examination as well as draw a blood sample for screening. Many conditions, including disorders of the liver, kidneys or blood, are not detected unless blood testing is performed. Such tests are especially important before any kind of surgery. We require that all pets have pre-anesthetic screening.

I.V. (Intravenous) Fluid Therapy

Under most circumstances, pets have been "fasted" and water withheld for a period of time prior to surgery. This has been recommended so that your pet has an empty stomach during his/her procedure to avoid vomiting and secondary aspiration pneumonia. IV therapy can help support their hydration levels and blood pressure and help with administration of emergency drugs if needed, which are all important during anesthesia/surgery.

Consent

IV fluid therapy is included with the cost of the dental procedure and and IV catheter will be placed. Please check if you have read and understand.

Pain Control After Surgery

Pain control during and after surgery is an important aspect of the healing process while also providing comfort to your pet. Pain medications will be prescribed to your pet based on the discretion of your veterinarian. Post-surgery injections and take-home medications are based on weight of pet. Pain medication will be dispensed if your pet has any extractions and/or deemed necessary by the veterinarian. Additional cost of $10-$35 will be charged if pain medication is prescribed.

Consent

I agree to the above stated.

Extraction of Teeth

When your pet is under anesthesia for dental cleaning, a veterinarian will examine the teeth and determine if any need to be extracted. This cost varies depending on which tooth and/or teeth will need to be extracted.

Do you give permission to remove teeth?

If you cannot be reached at the provided phone number:

Secondary Services Offered to Surgical Patients

Your pet has been admitted to the Animal Clinic today for the procedure listed on the front of this Consent Form. Many times, owners will request that other services be addressed while their pet is in our care. If you would like the veterinarian and staff to provide additional services to your pet, please indicate from the list provided.

Additional Services

Toe Nail Trim (no charge)
Ear Cleaning ($12.00)
Express Anal Glands ($31.00)
Heartworm Test ($42.50)
Identification Chip ($42.50)
Fecal - Annual ($30.00)
Other

Select all you would like performed on your pet

Other

Payment for Services

Payment is due in full at the time of service. You will be expected to pay your entire bill just prior to your pet being discharged from the Animal Clinic unless you and your veterinarian at the Animal Clinic, Inc. have made other arrangements. We accept credit card and debit card payments.

Owner's Release

Consent

The doctors and staff of the Animal Clinic, Inc. are to use all reasonable precautions against injury, escape or death of my pet. I understand that anesthesia involves risk to my pet which can be as severe as death. I also understand that surgical results cannot be guaranteed. I will not hold the Doctors or staff of the Animal Clinic, Inc. liable for an adverse outcome.

Compassionate, quality petcare since 1947

Compassionate, quality petcare since 1947