Dental Cleaning Release Form

Species/Pet Name *

(Dog/Cat) Pet Name

Today's Date *

Date

Date of Procedure *

Date

Owner's Full Name *

First Name Last Name

Phone Number *

Area Code Phone Number

Owner Responsibility: Please check each box signifying that you have read the foregoing and agree. *

I understand that home care administered by myself or a designated caretaker may be required to achieve best overall success. It is my responsibility to notify Family Pets Vet Care before altering the doctor’s recommendations. I understand that changes, supplementation, or alteration of any prescriptions may possibly result in an unfavorable or detrimental side effect with medical complications. I agree to make myself available by telephone during the approximate time interval of 9:00am to 1:00pm the day of the procedure. Home care instructions will be provided at the time of the pet’s discharge. I understand that payment for services rendered will bedue in full at the time of my pet’s discharge.

Procedural Information:

Anesthesia: Pre-surgical blood tests and a physical exam will enable us to assess and minimize risk of anesthesia to your pet.

Monitoring: To minimize anesthesia risk, we monitor the heart rate, blood pressure, respiration rates, temperature, and oxygenation.

Pain Management may be necessary in some dental procedures. The doctor will administer pain medications according to your pet's need, which can be an additional fee ranging from $15-40.

Antibiotics may also be necessary and will be prescribed by the doctor according to your pet's need for an additional fee ranging from $10-60.

Pre-Op Blood Work is required for any patient undergoing anesthesia to ensure that kidney and liver function is adequate to process and eliminate anesthesia.

An Intravenous Catheter is also required for all patients. For sterility, hair will be shaved over a vein on the leg so that the intravenous (I.V.) catheter can be placed. Blood pressure may lower during anesthetic procedures and fluid therapy aids in supporting your pet's internal organ systems before, during, and after surgery. It also allows immediate access to the vascular system in case of an emergency. This procedure is highly recommended, especially for those with known medical conditions or advanced in age.

Elective Procedures

Nail Trim ($0) Express Anal Glands ($20) Ear Cleaning ($20) Microchip ($40) Update Vaccinations ($ will vary)

Patient Information Section

Has your pet had any vomiting, diarrhea, or coughing within the last 20 days? *

If yes, please explain in the details box.

Has your pet ever had seizures? *

If yes, please explain in the details box.

Is your pet allergic to any medications, anesthetics, or vaccines? *

If yes, please explain in the details box.

Is your pet presently on any medication(s) including OTC medications? *

If yes, please explain in the details box.

Details:

Extractions:

It can be difficult to predict if teeth need extraction when an animal is awake because tartar and movement interfere with the assessment. Severely diseased teeth can cause considerable pain and discomfort and are a source of infection for other organ systems (liver, kidney, lungs, heart, etc.). During the dental cleaning, the teeth are evaluated and if found to be diseased they may required extraction or referral to a dental specialist for repair. The cost of extraction varies depending on the amount of time taken and the difficulty of removal and can range from $7 to $36 per tooth.

Please choose ONE: *

I authorize all medically necessary extractions to be performed. I would prefer to seek out a dental specialist for further treatment such as root canals, fillings, and orthodontics. I DO NOT authorize any extractions. (Please note that if you choose this option, a second anesthetic procedure may be necessary to removed affected teeth at a later date).

Flea Treatment: Should your pet have any fleas present at the time of surgery, a Capstar treatment will be administered at a charge of $7.50 to prevent the spread of fleas to other patients. Capstar kills all fleas for 24 hours. If you would like us to administer a flea/tick preventative instead, please notify the staff. *

I have read the above and agree.

Authorization:

I HAVE READ AND FULLY UNDERSTAND THIS ANESTHESIA AND SURGERY CONSENT FORM. I authorize anesthesia and surgery for my pet, as described above. The nature and risks of this procedure have been explained to me. I understand that some risks always exist with anesthesia, surgery, and dentistry, and I am encouraged to discuss any conserns I have about those risks with the hospital's medical staff before the procedure(s) is/are initiated. Additionally, I authorize Family Pets Veterinary Care to perform any diagnostic, medical treatment, surgical procedure, or dentistry as deemed necessary for any unforeseen medical or surgical complications if one should arise. While Family Pets provides the highest quality of anesthesia monitoring, surgical services, and dentistry, I completely understand the possibility of unforeseen complications that may occur during any associated anesthetic, surgical procedure, or dentistry. I fully acknowledge and understand these medical risks. I recognize that the veterinarian and clinic staff will do all that is necessary to minimize such risks. I will hold harmless Family Pets Veterinary Care, the veterinarian, or any clinic staff member liable for any complications that may or should arise in my pet's medical treatment and care. I understand that the clinic is not liable for any lost or damaged personal property (leashes, collars, etc) that are left in the clinic. No warranty or guarantee has been offered or given to me as to the results or cure afforded by these treatments or procedures.

Signed,

Name *

First Name Last Name

Pet Name *

Phone Number day of procedure *

Area Code Phone Number