Spirit of 76th Veterinary Clinic Dental Procedure Consent Form
Please enter a valid phone number.
Which do you prefer?
Will your pet be brought in
On a leash
We now require a $100.00 deposit when scheduling a dental appointment. At the time of the dental service, this $100.00 deposit will be credited to the balance due. (If the client does not show up on the day of the scheduled appointment, the deposit will not be refunded.)
I understand and agree
Dental: Includes oral exam, full mouth x-rays, teeth cleaning/polishing, antibiotic and anti-inflammatory injections given In-house, Mini Profile - Chem10 and IV catheter. (Dogs starting at $600.00 Cats starting at $500.00) Extraction consent below, please choose 1.
Proceed (We will proceed with any extractions the Dr. feels necessary.)
Attempt to Contact (We will attempt to contact you, if you do not answer, we will then proceed with any extractions the Dr deems necessary.)
Do Not Proceed (We will attempt to contact you but if you do not answer we will not proceed with any extractions.)
Please note: All bloodwork should be done in the 3 weeks prior to the dental procedure.
I understand and agree
Any additional bloodwork you would like done today? Please see description above.
Full Profile Chem 15 (8+ years) Cost $28.00 additional
Comprehensive Profile (8+years or questionable health status) Cost $89.00 additional
I decline additional bloodwork at this time
Update needed vaccinations. Please see above for description.
Any other procedures you would like done today? (Exam, HomeAgain Microchip, Heartworm 4dx test, Feline Triple, Fecal Parasite Testing)
Has your pet been given any medications in the last 12-24 hours? If yes, please specify what meds and time given.
Consent to perform procedures
Please read and mark all the boxes below
I am the owner or agent of the animal described above.
I have authority to execute this consent and am over the age of 18.
I hereby authorize and direct the veterinarians of Spirit of 76th Veterinary Clinic to perform the above described procedure(s).
The nature and purpose of the procedure(s) has been explained to me and I understand that no guarantee exists as to the result of diagnosis and treatment of said animal.
I authorize the Doctor to do Any Additional Procedures in the case of an Emergency
I confirm that that my pet has had no food since 10pm yesterday. (For anesthetic procedures only)
When the Doctor needs to get ahold of me, before 3pm today, I WILL be able to be reached at
Should be Empty: