AUTHORIZATION FOR DENTAL PROPHY

Name*

CLIENT FIRST NAMELAST NAME

Patient Name:*

Breed:*

Phone Number:*

Area CodePhone Number

Email:*

example@example.com

Additional Procedure(s):

Have you talked to your pet's doctor about the reasonable medical and/or surgical treatment options for your pet?*

Have you talked to your pet's doctor about sufficient details of the procedure to understand what will be performed?*

Have you talked to your pet's doctor about how fully your pet will recover and how long it will take?*

Have you talked to your pet's doctor about the length and type of follow up care and home restraint required?*

Have you talked to your pet's doctor about the most common and serious complications?*

Have you talked to your pet's doctor about the estimate of fees for all services?*

I certify that I ___________ over 18 years of age.*

DISCLOSURES:

I agree that I am the owner, or agent, of the pet identified above, over the age of 18, and authorize the veterinarians at Waverly Animal Hospital to perform the above procedure(s).

I have been informed that my pet is in need of preventative or therapeutic dental care and hereby consent to the appropriate procedure(s) described to me by staff veterinarians at this facility. These procedures may include, but are not limited to, the following: 1) dental prophylaxis (routine cleaning and polishing), 2) extractions, 3) oral surgery to close gaps left by extractions, 4) dental x-rays, and 5) antibiotic gel implants.

I am aware that dental procedures for animals require the use of anesthesia to: 1) maximize the visualization of the gums, teeth, and oral cavity, 2) minimize movement and discomfort, and 3) provide for the safety of the pet, doctors, and hospital staff.

I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending doctor before the procedure(s) is/are initiated. These may include, but not be limited to: the reasonable medical and/or surgical treatment options available, sufficient details of the procedure to understand what will be performed, how fully your pet will recover and how long it will take, the most common and serious complications, the length and type of follow-up care and home restraint required, and the estimate of the fees for all services. Nevertheless, all questions and concerns about the recommended dental procedures have been answered to my satisfaction.

While I accept that all procedures are performed to the best of the ability of the staff at this facility, I certify that no guarantee or warranty has been made regarding the results that may be achieved.

I agree to pay a deposit of 50% of the estimated fees, or $200, whichever the doctor requests prior to drop-off and assume financial responsibility for the remaining fees, agreeing to provide payment via cash, credit card, or check at the time my pet is discharged.

Initial that I agree to the above 6 disclosures:*

I am aware that dental procedures for animals require the use of anesthesia to: 1) maximize the visualization of the gums, teeth, and oral cavity, 2) minimize movement and discomfort, and 3) provide for the safety of the pet, doctors, and hospital staff. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending doctor before the procedure(s) is/are initiated. Nevertheless, all questions and concerns about the recommended dental procedures have been answered to my satisfaction.

Initial:*

FOR ANESTHESIA RISK

I have been informed that examinations under anesthesia often reveal (via x-ray) abnormal teeth that should be extracted to prevent oral discomfort and ongoing infection of the surrounding bone. I also have been informed that the loss or removal of one or more unhealthy canine teeth occasionally allows for an awkward protrusion of the tongue to one side or the other.

I (fill in the blank) authorize all medically necessary extractions at this time.*

Additional fees will apply.

Initial:*

FOR EXTRACTIONS

While I accept that all the procedures will be performed to the best of the ability of the staff at this facility, I certify that no guarantee or warranty has been made regarding the results that may be achieved.

Initial:*

FOR NO GUARANTEE OF PROCEDURE

I agree to assume financial responsibility for any fees related to this procedure, agreeing to provide payment, in full, via cash, credit card, or check at the time my pet is discharged. Any deposit made previously will be applied to the balance.

Initial:*

FOR PAYMENT DUE AT TIME OF RELEASE/DISCHARGE

Should unexpected life saving emergency care be required and the hospital staff is unable to reach me, the staff (__fill in the blank__) my permission to provide such treatment. I am aware to stabilize my pet, there will be additional fees and I agree to pay. *

Additional fees will apply to stabilize my pet

Initial:*

FOR LIFE SAVING CARE SELECTION

Pre-Anesthetic Blood Testing is REQUIRED for all pets. If you pet is over the age of 7, the chemistry full panel is required. Which blood test would you like performed today?

YesNo

Pre-Anesthetic Blood Testing is REQUIRED for all pets. If your pet has had a full panel of bloodwork within the past 90 days, your veterinary may opt to not repeat the bloodwork. Please select the option to confirm you have read this requirement.*

** We require the rabies vaccine and fecal tests on all pets. We also require DHLPP, Bordetella, Heartworm Test for dogs and RCP for cats.

I realize that all of the following are recommended because the well-being of my pet is the top priority.

Are any preventative services due now (or soon) that you would like performed? Rabies/Distemper/Leptospirosis/Bordetella/Lyme/Influenza/Leukemia vaccines, Intestinal Parasite Screen for stool, Heartworm test for dogs, or Leukemia/FIV test for cats). We require: RV, DHLPP, Bord., heartworm test (if over 7 months old) & stool sample for dogs and RCP, Rabies & stool sample for cats. (NOTE: Any required items will be performed, at owners expense, unless proof of service is provided at drop off)*

YesNo

If yes, what would you like performed?

Rabies (RV), Canine Distemper (DHPP), Leptospirosis (Lepto), Heartworm Test (4DX), Intestinal Parasite Screen/Fecal (FA), Bordetella (INB), Lyme, Canine Influenza, Feline Distemper (RCP), Feline Leukemia/FIV Test (FELV/FIV), Feline Leukemia vaccine (FeLeuk)

Would you like a microchip inserted? If yes, please complete the address section below.*

YesNo

Address for microchip registration, or to update your client file:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

If yes, please include your complete address for the registration:

When did your pet last eat?*

DateHourMinutesAM/PM Option

Please list any additional medications your pet is on (drug name, strength, directions, date and time last given):

Do you need refills of any medications, supplements, preventatives, or food?

Please include drug name and quantity requested.

I have read and fully understand the above terms and conditions set forth above.

Signed,*