Dental Cleaning Admission and ConsentDental Cleaning Admission and Consent In order to make your pet’s surgery drop-off as efficient as possible, please fill out the following information before your upcoming appointment. After you submit this form, it will be emailed to us and become part of your pet’s medical record.Client Name* First Last Pet’s Name*Date of Appt* MM slash DD slash YYYY Best email address to send your exam report card to after your appointment* Section 1. Patient HistorySurgical procedure*Do you have any concerns with your pet at home?* Yes Noplease elaborate*Have you noticed any increase or decrease in your pet’s appetite or water consumption?* Yes Noplease elaborate*Have you noticed any changes in your pet’s urination or defecation?* Yes Noplease elaborate*Has your pet experienced any vomiting or diarrhea in the last 72 hours?* Yes Noplease elaborate*Has your pet experienced any unreported illness or injury in the last 30 days?* Yes Noplease elaborate*Has your pet experienced any adverse reactions to medications or anesthesia in the past?* Yes Noplease elaborate*Is your pet currently on any medications or dietary supplements?* Yes NoIf yes, please list any medications, doses and when they last received them*Does your pet have any allergies?* Yes Noplease elaborate*Would you like to have your pet microchipped during this procedure?* Yes NoIf you pet is undergoing any type of soft tissue procedure today, we may send you home with an e-collar to ensure the best possible post-op recovery ($8.50-$12.50 depending on size). *If you already have an e-collar at home please bring it with you at the time of your discharge appointment and we will ensure it is still an appropriate fit.Please note: Appropriate treatment will be administered at your expense to any pet with evidence of fleas, flea dirt, or ticks.Section 2: Anesthesia/Sedation/Procedure ReleaseI verify I am the owner (or Authorized agent for the owner) of the above named pet and authorize the above procedure to be performed. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure(s) as directed by the veterinarian.I have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any anesthesia episode, even in apparently healthy animals and have discussed my concerns with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. I accept responsibility for any result in additional charges.I agree to be responsible for any charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital), but will be checked in on at least once overnight by a technician.* I verify I am the owner (or Authorized agent for the owner) of the above named pet and authorize the above procedure to be performed. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure(s) as directed by the veterinarian.* I have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any anesthesia episode, even in apparently healthy animals and have discussed my concerns with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. I accept responsibility for any result in additional charges.* I agree to be responsible for any charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital), but will be checked in on at least once overnight by a technician.Section 3: Oral Surgery and Additional Preventive DentistryYour pet will receive full mouth dental radiographs during their full anesthetic dental cleaning today. Dental radiographs are the only way to truly evaluate your pet’s complete dentistry needs as most periodontal disease lies beneath the visual surface of the gums. Due to this we often encounter problems that require further intervention unforeseeable until your pet has already been placed under anesthesia. This intervention may include but is not limited to; performing periodontal bonds and sealants to protect teeth from further fractures/damage, use of antibiotic gels to seal the beginning formation or intraoral pocketing and performing dental extractions to prevent the progression of periodontal disease resulting in infection and/or oral bone loss in affected teeth. Please choose one of the options below regarding additional dentistry and our communication with you regarding your pet’s needs:Please select your choice below* Please call me prior to performing any additional dentistry required for my pet. You may proceed with any additional dentistry my pet requires up to $500.00 above the cost of my pets preventative dental cleaning. Please contact me if my pet’s recommended care will exceed this amount. * You may proceed with any additional dentistry my pet requires.** Please note it is pertinent that you will be readily available at the phone number you have provided to us during your pets time in our care. We will attempt to call you while your pet is under anesthesia in order to honor your selection above. In the event that you cannot be reached, your pet will be recovered from anesthesia no more than 5 minutes after the time of our initial attempt to contact you. In the event we cannot reach you, please understand that we may leave causes of periodontal disease untreated which may incur further costs in the future which you will accept full responsibility for.Phone number(s) where you can be reached TODAY*Signature*Reset signature Signature locked. Reset to sign again Δ
