Dental Consent Form

Client Name

First NameLast Name

Patient Name

Requested Surgical Procedure

Date

It is difficult to predict all circumstances of a procedure and thus variations in cost may occur. If during hospitalization or surgery, a change in treatment or new problem is found, an attempt will be made to contact the owner to inform them. If contact cannot be made a decision may have to be made regarding the urgency of the procedure. In this case, if it is deemed life threatening, the procedure may be performed without notification.

Emergency Phone Number

May we text you pictures and updates? If so please list a text number below.

Cell Phone Number

Is your pet currently taking any medications?

YesNo

If yes, please list any prescription, over the counter medications, or supplements AND date and time of last dose.

Does your pet have any allergies that you know of?

YesNo

If yes, please list allergies

RISKS:

The anesthetic risk of serious complications from routine procedures on healthy animals is less than one in 5000 in our practice. The risk is higher in animals with health problems. The required physical examination will discover 95% of these problems. Pre-operative procedures such as x-rays, blood tests and electrocardiograms may help detect underlying problems that are not apparent from physical exam and history. Health problems that increase the risk are more likely in animals over eight years old. While helpful, all of these tests together would increase the cost by $170 to $250. Therefore they are usually not done unless there are known risk factors, suspicious signs or if the owner requests them. If you wish this or other preoperative blood tests we can provide them at the East Suburban Animal Hospital even on the same day as surgery. A packed cell volume, total protein, white blood cell count, BUN, ALT and Glucose are highly recommended in animals over 8 years old. Please advise us before surgery.

I understand if tests are not performed, underlying disease processes may be missed.

I decline blood testsI authorize blood tests ($90.00-$95.00)

EXTRACTION CONSENT

Your pet is being admitted for a comprehensive oral health assessment and treatment. This is a rough estimate of the expected expenses for your pet based on the initial visual exam. It is good for 30 days. Sometimes with dental disease,
problems that are present may not be revealed until a thorough exam under general anesthesia is performed. Dental radiographs are utilized to assess disease below the gum line during this exam. Since it is difficult to predict the extent of disease process on a rough visual exam, variations in cost may occur. In cases where further work is required and further expenses may result, every attempt will be made by the doctor to contact the owner, to discuss the case. If contact cannot be made at the phone numbers provided within 15 minutes and the nature of the procedure is deemed an emergency, a decision may have to be performed without prior notification. In other cases the procedures are of a non-emergency nature (non-life threatening), but are deemed both necessary and desirable for the health of the pet in the attending veterinarian's professional judgement, you will have the opportunity to choose an option below on how to proceed.

Dental procedures, including simple and surgical extractions can be associated with risks. I understand these risks may include broken tooth roots, bleeding, dry sockets, and damage to surrounding tissues. Rarely, fracturs of the bone may occur, necessitating further work. At our hospital, every effort is made to predict and avoid these complications but unforeseen events may occur.

Please indicate how you wish us to proceed with dental extractions

Have the doctor proceed with all procedures, including unforeseen tooth extractions as determined by the attendingdoctor.Have the doctor proceed with all procedures, including unforeseen tooth extractions, up to $ ________ cost. Pleasecall to discuss the case if more work is needed beyond this cost. If I am unable to be reached, only part of the neededwork will be done and the procedure may be finished at a later date. This will increase the total cost of the work.Call me if any additional work, including unforeseen tooth extraction, is needed. I understand that if I cannot bereached, no additional work will be performed and may have to be completed at a later date. This will increase the totalcost.I prefer my pet be referred to a board certified Veterinary Dental Specialist and do not authorize any extractions.

DENTAL RADIOGRAPH CONSENT

I understand that disease below the gum line involving the tooth roots and all surrounding tissues cannot always be assessed without dental radiographs. The fee for Dental Radiographs is $84.00-$126.00 depending on how many views
are necessary.

Please indicate how you wish us to proceed with dental radiographs

I authorize the attending doctor to proceed with dental radiographs as deemed necessary.I do not authorize any dental radiographs.Call before dental radiographs are done.

PAIN MANAGEMENT

Animals have pain with surgery and we feel an obligation to provide pain relief. This will be provided the morning of the surgery before the surgery begins, during the surgery and for 3 - 7 days afterward depending on the type of surgery. A supply of pain medicine will be dispensed or prescribed for you to give at home. The doctor will decide on a case-by-case basis which medication is best for your pet. The quote given with the estimate is the cost of our usual protocol but may vary as indicated. I understand that no guarantee for success can be given and that some risks are involved in all procedures. The risks have been explained to my satisfaction and the East Suburban Animal Hospital has my permission to perform the above procedure.

REQUESTED VETERINARIAN:

A specific veterinarian will perform the procedure ONLY IF REQUESTED AND INITIALED HERE. I understand that in an emergency situation, any veterinarian at the East Suburban Animal Hospital may need to take action and give needed care and there may be additional charges.

Specific Veterinarian or write N/A Initial

I understand East Suburban Animal Hospital is NOT a 24 hour facility.

Surgery patients are discharged in the back of our building. Please park in the rear parking lot, go up ramp, and ring the doorbell. One of our technicians will go over all of your pets post-surgery care. We make every effort to call you after your pet has waken from surgery, however if you do not hear from us, please call after 4:30 pm to check when they may go home.

If your pet is going home the following day, discharges before 1:00 pm are done at our cashier location in the front of the building and after 1:00 pm at the back. By electronically signing below I authorize East Suburban Animal Hospital to perform the above listed services.