Dental Cleaning Consent

Name *

First Name Last Name

Your Pet's Name

Procedure Date

Best number to reach you at on the day of your pet's procedure: *

Area Code Phone Number

Please select if you prefer a text.

Yes please text the number above

Additional phone number if I cannot be reached at the number above.

Area Code Phone Number

Email

example@example.com

Like you, our greatest concern is the well being of your pet. Prior to anesthetizing your pet, our doctors take the following measures for every dental patient.

Dental Requirements: Some additional services may be required based on your pets health, the surgical procedure and the Dr. recommendations.

A pre dental exam is performed on all patients before anesthesia.

Anesthetic monitoring is performed by our trained staff. Heart rate, body temperature, pulse oximetry and respiratory rate are some of the specific parameters we monitor. These vital signs are continuously assessed to help create the safest anesthetic environment possible. In addition to the above essential monitoring we also offer to monitor blood pressure, electrocardiogram, core body temperature, and end tidal CO2. Additional Monitoring is an addition cost.

Additional Services may be required based on your pet's health, the dental procedure and the Dr. recommendations. These services and costs were discussed during your dental consultation and estimate review.

The control of pain is very important aspect of the surgical procedure. Our goal is to minimize the inherent discomfort associated with all surgical procedures. A pain free animal requires a lower level of anesthesia, increasing the safety for your pet and helping to ensure a smooth and speedy recovery. Our pain management protocol is required in all surgical patients. The medications used and length of treatment will vary based upon the procedure performed and the degree of pain involved. If needed, further out-patient medications will be prescribed for your pet to continue at home.

Blood testing (Complete Blood Count (CBC), Chemistry Panel, Electrolytes): Blood testing is advised on all pets prior to anesthesia. Many conditions, including disorders of the liver or kidneys, low grade infections, or electrolyte abnormalities can only be detected through blood testing and examinations, especially before your pet shows clinical signs of illness. Detection of these conditions prior to surgery will decrease the risks associated with anesthesia. In many cases, such as geriatic or sick patients, the doctor may require blood testing prior to anesthesia. Our in-house laboratory is equipped with the latest technology to perform blood screening tests. If a problem is detected during the physical exam or on the blood work, a doctor will contact you to discuss any recommended course of action prior to surgery. Surgery will be postponed if it is deemed to be in the best interest of your pet.

IV Fluid Therapy: is important to the maintenance of homeostatis during anesthesia and provides venous access for supportive therapy, for maintenance of anesthesia, and for cardiopulmonary resuscitation. There will be a small shaved portion on your pet's leg.

Therapy Laser: We also offer our therapy laser as a post-op service to help provid immediate pain and swelling relief at any surgical site. This quick, pain-free procedure desensitizes nerve endings and promotes healing of the tissues involved. Therapy is not advised around the eyes or in situations with suspected cancer.

Options that are advised while your pet is here for a dental procedure (please check box to authorize) additional fees apply. *

Yes, I understand and consent to services

When did your pet last eat? *

In the past 48 hours, please select if your pet has experienced any of the following:

Coughing Sneezing Vomiting Diarrhea None

Is your pet on any medications, if so, please list the medications and when they were last given.

Does your pet need a refill on any medications listed above?

Yes No

Do you have any additional concerns for the doctor today?

Does your pet have a history of seizures or other neurologic disorder?

Yes No

Please select any services you would like performed while your pet is under anesthesia:

Anal Gland Expression Microchip Update any vaccinations due or coming due in the next 2 months Clean/Check ears

In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedures today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference: *

Please proceed with life-saving measures. I will accept responsibility for all costs incurred. Please do not proceed with life-saving measures. I accept responsibility for all costs incurred.

Please select one of the following: I have been informed that examinations under anesthesia often reveal diseased teeth without adequate bone support or that pose a threat to the structure of surrounding teeth. It may be recommended that such teeth be extracted to prevent oral discomfort and ongoing infection of surrounding bone. *

I give the doctors of North Ogden Animal Hospital permission to perform any necessary oral surgical needs ( tooth extractions, growth removal, etc.) without contacting me. I understand that such procedures will result in additional costs that may not have been on the estimate. Please call before performing any oral surgery or tooth extractions. If I am not available to be reached while my pet is undergoing anesthesia and dental care, I give permission to do what is necessary and consent to additional extractions at the discretion of the doctor and agree to pay for all related fees. Please call before performing any oral surgery or extractions. I understand that if I am not available, no procedures will be performed without my authorization, even if deemed necessary.

Signature *

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Date *

Date