Oral Assessment Treatment & Prevention (ATP) Estimate

Berkeley Dog & Cat Hospital

Oral Assessment Treatment & Prevention (Oral ATP) Consent
Owner's Name*

First NameLast Name
Best contact number for questions during time of procedure:*

Area CodePhone Number
Pet's Name*
Pet's Age:
Pet's Species*

CanineFeline
Breed & Color*
Oral Assessment Treatment & Prevention Plan (Oral ATP) Consent
Includes:
- Pre-anesthetic examination
- Anesthesia and anesthetic monitoring
- IV catheter and fluids
- Dental cleaning, polishing & fluoride treatment
- Dental radiographs (x-rays)
- Dental charting
- Assesment of oral health status
- Development of treatment plan
- Hospitalization
- Complimentary recheck examination
May include:
- Blood tests (if not already performed)
- OraVet Sealant
- OraVet home care kit
- Additional services as indicated
Other procedures, if indicated, are performed at an additional charge. Such procedures might include periodontal surgery, root-planing, root canal therapy, extractions and pain management. Additional costs can be significant.

As part of your pet's Oral ATP, the teeth will be individually examined and their condition charted. We will make a dental treatment plan and attempt to call you with an update.

However, calling you means that your pet will endure additional anesthesia. If we cannot obtain permission to proceed with the treatment plan, we may need to perform more anesthesia and expense at a later date.
Therefore, we would like you to choose one of the following options for today's procedure:*

I prefer Berkeley Dog & Cat Hospital to do any procedures they deem appropriate.I prefer to be contacted prior to any additional procedures. However, if I cannot be reached I authorize unforeseen, non-emergency procedures (including extractions) up to $600.00.I prefer to be contacted prior to any additional procedures. However, if I cannot be reached I do not authorize unforeseen,non-emergency procedures (including extractions.)
Hospitalization Code Status
While your pet is admitted to the hospital, our staff will make every effort to prevent complications arising from your pet’s illness/injury or from planned sedation or surgical procedures under anesthesia.

While under our care, if your pet suffers respiratory arrest (stops breathing) or cardiac arrest (the heart stops), we need to know your wishes concerning treatment.

All patients admitted to Berkeley Dog & Cat Hospital must have a resuscitation directive regardless of severity of illness.
Please choose one of the following options for today's procedure:*

CPR: I wish the staff of Berkeley Dog and Cat Hospital to perform CPR (Cardio Pulmonary Resuscitation) on my pet if my pet suffers respiratory or cardiac arrest with no guarantee of survival. The estimate for initial CPR is $300 to $500.DNR, and authorization of humane euthanasia: - If my pet suffers respiratory or cardiac arrest, DO NOT perform CPR. Please provide any additonal drugs needed to help my pet pass with ease.DNR - Do Not Resuscitate: I DO NOT want CPR performed on my pet. I understand that if my pet undergoes respiratory or cardiac arrest, they will eventually pass, but death may not be instantaneous. Do not administer any additional drugs to facilitate their passing.
Acknowledgement
This is only an ESTIMATE of charges for procedures discussed and agreed to during your pet's examination. In most cases, it is impossible to definitively estimate all expenses until cleaning, polishing, and the examination are performed under anesthesia, and radiographs have been taken.

I assume responsibility for all charges and services incurred for the patient named above and agree to pay such charges at the time of release.

I agree to pay a deposit of 100% of the low end of estimate fees and agree to pay the remaining fees, and provide payment via cash or credit at the time my pet is discharged from the hospital.
Please confirm:*

I authorize the doctors and staff to provide the procedures listed above. I understand that Berkeley Dog & Cat Hospital uses the safest diagnostic, anesthetic and surgical protocols available to minimize any risk to your pet. Some side effects of anesthesia may include mild nausea, prolonged recovery, or, in very rare cases, death. I have been advised of the nature of the procedures and of the potential risks.I do not authorize Berkeley Dog & Cat Hospital to provide the procedures listed above.
I am the owner or agent for the owner and have the authority to execute this consent. I have read and understand the agreement.*

Clear
Should be Empty:

Berkeley Dog & Cat Hospital

Oral Assessment Treatment & Prevention Plan (Oral ATP) Consent

Hospitalization Code Status

Acknowledgement