Dental

Patient Information *

Pet's Name Last Name

Breed *

Age/Date of Birth *

Best phone number *

Area Code Phone Number

Alternate phone number

Area Code Phone Number

Date of Appointment *

Date

Procedure(s) to be performed *

Ex: Spay, Neuter, Dental, Extractions, Mass Removal, Wound Repair, Ear hematoma etc

Has your pet had any food or water since midnight last night? *

Current Diet *

Has your pet been coughing, wheezing, or breathing hard? *

Has your pet been vomiting or having diarrhea? *

Do you want your pet microchipped? (additional charges apply) *

Does your pet have any allergies? *

If yes, please list:

Has your pet ever had an adverse reaction to medication? *

If yes, please explain:

Is your pet taking any medications? *

If yes, please list medications, dosage and time last given

I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize the above procedure to be performed by All Creatures Animal Clinic. 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 as directed by the veterinarian. I have been advised as to the nature of this procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand there is always a risk associated with any anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. Procedure risks include serious bodily injury (including, but not limited to: eye injuries, broken teeth, broken jaw) or death. 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. We may identify additional problems during the dental procedure that could not be identified beforehand, such as broken or abscessed teeth, bone loss, deep pocketing, etc. These problems are best dealt with while your pet is under anesthesia. Please indicate how you would like for us to proceed if extractions or additional procedures are warranted. *

I authorize the veterinarian to proceed with any necessary treatment for my pet, including extractions, regardless of cost. I authorize the veterinarian to proceed with any necessary treatment for my pet up to a predetermined amount. I understand I will not be contacted unless the total cost of services exceeds that amount. I DO NOT authorize the veterinarian to authorize the veterinarian to proceed with additional treatment without my consent. I understand if I am unable to be reached by phone, my pet will be recovered from anesthesia and an additional anesthetic procedure will be needed to correct the problem, which will be at an additional cost.

I agree to be responsible for all 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). In the event of an unforeseen emergency, we will attempt to reach you without delay. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. *

Please PROCEED with life-saving measures. I accept responsibility for all costs incurred. Please DO NOT PROCEED with life-saving measures. I accept responsibility for all costs incurred.

I have read and understood the information printed above. Please sign below. *

Clear

Date

All Creatures Animal Clinic Patient Admission and Consent Form- Including Dentistry