Dental Authorization

Date

Name

First NameLast Name

Pet's Name:

Best Contact Phone Number

Please enter a valid phone number.

Alternate Contact Phone Number

Please enter a valid phone number.

May we send a text message:

YesNo

When did your pet last eat?

Please list any additional problems, concerns or questions:

Please list any current medications and when the last dose was given:

Pre-anesthetic lab work:

Lab work prior to anesthesia and surgery is essential to evaluate your pet for underlying problems that could interfere with the procedure. A CBC looks for signs of anemia and changes in white blood cells and platelets. A chemistry panel checks organ functions and electrolytes. In general, a Chem 10 is recommended for young patients with no health concerns. A more comprehensive Chem 17 is recommended for senior patients or those with existing health concerns.

Lab work has already been completed:

YesNo

I would like lab work on my pet today prior to anesthesia:

CBC and Chem 17 + electrolytes ($263.05)CBC and Chem 10 + electrolytes ($221.55)

Pain Relief:

Hillside Pet Clinic understands the importance of pain management and offers effective methods to meet specific needs. Administration of medication my be warranted before, during and/or after the procedure to reduce pain and discomfort for your pet. There is a separate charge for medication admistered orallly or by injection. Cost will vary on medication given here and to go home with your pet. The approximate cost will be $40-$120.

I authorize pain medication of be administered to my pet:

YesNo

Dental X-Rays:

We take full-mouth dental x-rays on all of our patients in order to accurately diagnose the the condition of your pet's teeth.

Dental Extractions:

It is difficult to accurately assess the need for extractions without a complete oral exam and x-rays, so any extractions that may be needed are additional and we can provide an updated estimate once the full assessment has been done. Extractions are charged per tooth, dependent upon the complexity of the extraction. The cost ranges from $45.75 for simple, non-complicated extractions, up to $327.75 for difficult, very complex extractions. In addition to the cost of the actual extraction(s), there is a fee for sterile supplies and possibly a local anesthetic, which would add approximately $112.25 to the cost. Additional pain medication may also be needed, which is generally $25-$50, depending on the size of your pet.

If I am unreachable to discuss extractions, I authorize the Doctors to proceed with all medically advised extractions. I will be responsible for the additional charges.

YesDo not proceed with extractions if I am unreachable.I authorize all extractions medically necessary without being contacted first.

Sanos Dental Sealant

Applied after your pet's teeth are cleaned and polished. This is a one time application which lasts up to six months and is another choice in the delay of plaque and calculus. Fee: $178.25

Would you like Sanos applied to your pet's teeth today?

YesNo

Would you like your pet to be microchipped today ($85.00)?

YesNo

Would you like your pet's nails trimmed today? (Complimentary while under anesthesia)

YesNo

Would you like your pet's anal glands expressed today? (Complimentary while under anesthesia. Does not apply to exotic animals.)

YesNo

Would you like an updated estimate for today's procedure?

YesNo

Emergency Care Authorization

We believe in being well-prepared and would therefore like to know your preferences in the unlikely event of an emergency. Life-threatening complications are extremely rare, but should an event occur, we want to be able to act in accordance with your wishes. Hillside Pet Clinic will make attempts to contact you, but immediate action is essential. Please indicate your preferred emergency response for your pet by choosing one of the options below:

CPR and Emergency Treatment Request

I authorize Hillside Pet Clinic to begin lifesaving treatments on my pet. CPR steps include administering medication, chest compressions, and other emergency measures: $350-$500

Do Not Resuscitate (DNR) Request

Do not use resuscitation methods. I do not wish for CPR or any extraordinary measures to be used on my pet. I understand that in the event of a life-threatening emergency, my pet would not be expected to survive.

Please select one:

I authorize CPR and emergency treatment for my petDo Not Resuscitate (DNR) my pet

The nature and risks of this procedure have been explained to me. I understand that some risks always exist with sedation/anesthesia and/or surgery. I have been encouraged to discuss any concerns I have about the risks with my veterinarian. My signature indicates that my questions have been answered to my satisfaction. In the event that unforeseen complications arise during the procedure, I understand that reasonable efforts will be made to contact me to explain the procedure/treatment and obtain my instructions regarding them. However, if the efforts contacting me are unsuccessful, I authorize Hillside Pet Clinic to proceed as they deem is in the best interest of my pet. I fully understand the risk(s) associated with today's procedure. I will not hold Hillside Pet Clinic, its veterinarians and hospital staff liable for complications that may arise.

I agree

Signature