Dental Admission Checklist 2023

  • Dental Admission Checklist

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  • I understand, my pet CANNOT have any food or snacks after midnight prior to sedation. (You may offer ONLY water)*
  • Has your pet been coughing, wheezing, or breathing hard?*
  • Could your pet be pregnant?*
  • Is your pet on monthly heartworm preventative?*
  • Has your pet been vomiting or having diarrhea?*
  • Would you like your pet microchipped? (additional charges apply)
  • Does your pet have allergies?
  • Has your pet ever had anesthesia previously? If any issues please explain below*
  • Has your pet ever had an adverse reaction to a medication?*
  • Is your pet taking any medications?*
  • Pre-Op Blood Profile: We highly recommend this important blood test. It will enable us to rule out many preexisting internal problems (i.e. infection, anemia, kidney/liver function) that may not be evident physically, but could also lead to serious complications. Would you like the blood test?*
  • Dental Radiography: We highly recommend having whole mouth x-rays taken so your veterinarian can assess your pet's tooth roots and other subgingival structures. For pets under 20 lbs, the fee is $137, 20-60 lbs $160, >60 lbs $184. Would you like us to do these radiographs?
  • Annual Vaccines: Would you like to have these updated?
  • Select the vaccines or tests you would like updated:
  • If we find parasites, may we deworm your pet?
  • Do you need an estimate or more information on any services today?

  • Please note: 

    • A topical treatment will be applied, at the owner's expense; to any pet with the evidence of fleas, flea dirt, or ticks. 
    • An Elizabethan Collar may be required for your pet's comfort and protection. Prices may vary according to size. 
    • For the comfort of your pet, pain medication is given for all surgical procedures. 

  • Authorization

    I verify I am the owner (or authorized agent for the owner) of the named pet and authorize the above procedure to be performed by New Baltimore Animal Hospital. 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 the procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any anesthetic 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 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 life saving and/or additional procedures as are necessary in the veterinarian's professional judgement. I accept responsibility for any result in additional charges. 

  • We may identify addition 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 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. Very rarely do emergencies happen and we want to know your preference if no one can be reached. Please select your preference below:

  • Phone Numbers:

    Please list where you can be reached today during the procedure or in the event of an emergency.

    Also, after surgery and once your pet is awake, we will try to contact you with a progress report.

    I have read and understand the information printed above.

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