Dental Admission Checklist 2023

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 authorize the veterinarian to proceed with any necessary treatment for my pet, regardless of cost.I authorize the veterinarian to proceed with any necessary treatment for my pet up to: ______________________.I do not 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 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. Very rarely do emergencies happen and we want to know your preference if no one can be reached. Please select your preference below:

Please PROCEED with life-saving measures (CPR and resuscitation drugs). I accept responsibility of all costs incurred.Please DO NOT PROCEED with life-saving measures (CPR and resuscitation drugs). I accept responsibility for all costs incurred.

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.

Contact Name*

First NameLast Name

Date

Phone Number: (first number we will call)*

Area CodePhone Number

Phone Number: (second number we will call)

Area CodePhone Number

Owner/Owner's Agent Signature:

May we text you updates/pictures about your pet while here for surgery?

YesNo

Mobile Number:

Area CodePhone Number