Green Cove Pet Hospital - Dental Authorization Form

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Patient Name

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DENTAL AUTHORIZATION

I hereby authorize Green Cove Pet Hospital to perform the indicated procedures and associated anesthesia. I understand that unforeseen conditions may require an extension of a planned procedure. I hereby consent to and authorize the performance of such procedures or as are necessary and advisable in the professional judgement of the veterinarian. I am aware of and have been advised to the nature of the procedures and the risks that are involved, including death. I realize that results cannot be guaranteed.

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Pre-Surgical Testing

As veterinary medicine has advanced, we now have the capacity to properly evaluate {NAME}’s ability to utilize and metabolize drugs and anesthetic agents. The detection of underlying problems before surgery is even more important since {NAME} cannot tell us how they feel. The test we require evaluate the major organ functions and other common problems that may not be noted or seen visually. While performance of these tests helps decrease anesthetic and surgical risk, it cannot detect all potential health problems or eliminate all risk. They do not guarantee a cure.

All dogs MUST be current on Rabies, DHPP/DRCP, Bordetella, and have a negative fecal. All cats MUST be current on Rabies and FVRCP

Due to the fact we cannot control the flea and tick population outdoors, we highly recommend monthly topical flea treatment. If fleas and ticks are found on your pet, they will be treated at the owner’s expense with Capstar and a topical flea/tick treatment if necessary. This also applies to intestinal parasites upon exam.

During the physical examination, it is often not possible to completely evaluate the degree of dental disease. Only when your pet is under anesthesia can a thorough dental exam be done. Because of this, dental problems such as loose, diseased or fractured teeth may be later discovered while under anesthesia. We try to make a preliminary estimate accurate, but this is not always possible in the examination room. In order to accurately assess your pet’s dental needs, some additional procedures may be necessary.

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PRE-SURGICAL CARE

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Pre-Surgical Labwork

< 6yr, $76 (10 item internal organ analysis, electrolyte analysis, and complete blood count.)

6+yr , $143 (18 item internal organ analysis, electrolyte analysis, thyroid level evaluation, and complete blood count.)

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SURGICAL OPTIONS

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TOOTH EXTRACTIONS $10-$76ea (cost is based on the complexity of the extraction due to severe periodontal or endodontic disease, it may be necessary to extract some of these diseased teeth.)

Yes

No

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BIOPSY (if necessary) $202

Yes

No

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NAIL TRIM $13

Yes

No

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EAR CLEANING $14 **based on case in cats**

Yes

No

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POST-OPERATIVE CARE

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Microchip $43

Yes

No

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E-Collar $16-32 - Prevents pet from licking or chewing healing incisions.

Yes

No

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PLEASE NOTE: ANY CHARGES INCURRED DUE TO DAMAGE TO THE INCISION WILL BE THE RESPONSIBILITY OF THE OWNER.

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Proheart - 6 Mo Injection Heartworm Prevention

Yes

No

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Bravecto -3 Mo Flea & Tick Prevention

Yes

No

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In the event of cardiac arrest, please select desired response:

I DO request resuscitation to be performed on my animal

I DO NOT request resuscitation to be performed on my animal

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I have received, understand, and approve the estimate provided to me for {NAME}'s Treatment Plan

Estimate of charges: $    to

This is only an estimate of charges, not a quote. This is not a receipt or bill. It is an initial statement prepared to estimate expenses during your animal’s period of hospitalization.

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Is your pet currently taking any medication?

Yes

No

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If yes, please list

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Procedure to be performed

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Date

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* This field is required.

Client Name

The best phone number to reach you while your pet is in their procedure.

Is this a Cell/Landline?

Emergency Number

Is this a Cell/Landline?

Email Address

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Signature* This field is required.

Clear