Dental Authorization

Date

Name

First Name Last 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:

Yes No

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:

Yes No

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

CBC and Chem 17 + electrolytes ($183.50) CBC and Chem 10 + electrolytes ($154.20)

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 $34-$60.

I authorize pain medication of be administered to my pet:

Yes No

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. The cost ranges from $117-$173.

Do you authorize full-mouth dental x-rays:

Yes No

Dental Extractions:

If problem teeth are found during your pet's dental cleaning, extractions may be necessary.

Do you authorize dental extractions?

Yes No Please contact me first

Sanos Dental Sealant:

Applied after your pet's teeth are cleaned and polished, this one time application lasts up to six months to prevent the delay the formation of plaque and the development of calculus. Fee $115

Do you approve the application of Sanos Dental Sealant?

Yes No

Would you like your pet to be microchipped today ($55)?

Yes No

It is difficult to give an accurate estimate until your pet is anesthetized. On the average cats are ~ $545-$675 and dogs ~$725-$877. Have you been provided with an estimate for today's procedure?

Yes No

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

Yes No

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 conditions arise during the identified procedure or treatment, 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.

Signature

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