DENTAL PROCEDURE CONSENT FORM

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Date:*

Date

Name*

First NameLast Name

Pet's Name:

Species:

Sex:

Age:

Color:

Pre-Anesthesia Testing & Fluid Administration

Pets with tartar, infection, and other dental disease are more prone to other medical problems, such as heart disease or kidney disease. To ensure as safe a dental procedure as possible, blood tests are performed to assess the function of the liver and kidneys and to check for anemia. Blood tests should have already been done and the results discussed with you.

Intravenous fluids, given during the dental procedure, help provide adequate blood flow through the kidneys, heart, and other internal organs. Fluids also help eliminate anesthetic drugs post-operatively, often resulting in a quicker recovery from anesthesia. An intravenous catheter also gives immediate access to a vein should emergency medications be needed. All pets undergoing a dental procedure will have an intravenous catheter placed and will receive intravenous fluids during the procedure.

Pocket Probing & Clindoral Application

All pets undergoing dental cleaning receive thorough ultrasonic tooth scaling, polishing, and pocket probing. Probing checks for pockets between the teeth and gums that are deeper than normal. Deep pockets are an indicator of advancing periodontal infection. Early detection and treatment may save the teeth by stopping the infection. Treatment involves cleaning under the gum line and application of Clindoral, an antibiotic polymer compound. Clindoral fills the pockets with infection-fighting medication and helps prevent food and plaque from accumulating in the pockets again. If your pet needs Clindoral due to gum pockets, it will be applied. There is an additional charge associated with Clindoral treatments.

Dental X-Rays

If there is a question or concern about infection around the tooth, we will take an x-ray to determine if the tooth can be saved or if it needs to be extracted. There is an additional charge for X-rays if they are needed.

Tooth Extraction

If teeth are broken, severely infected or have damage to their roots, they may need to be extracted. This is for your pet’s health and comfort as these conditions are often very painful. It is difficult to know ahead of time if any of these conditions exist, but they will be discovered during the dental procedure. Teeth that cannot be saved will be extracted. Extraction requires oral nerve blocks, to numb that area of the mouth. There is an additional charge for oral nerve blocks and extraction of teeth, which varies with the number and type of teeth being extracted.

Post-operative Pain Management

Depending on the procedure your pet is having done, pain medication may be given here and/or sent home with you.

Extensive dental procedures

Some pets may require very extensive dental treatments such as multiple X-rays and extractions, requiring prolonged anesthesia. Occasionally, for the safety of your pet, we may elect to perform these treatments on two separate days so as not to keep your pet under anesthesia for too long. If we determine this to be in the best interest of your pet, we will call you during the procedure to discuss this and get your permission

Please select one option:

Perform any treatments that are medically necessary, including extractions. No phone call is needed to authorize treatments listed previously.Please call me to authorize treatments if total cost will exceed the cost of the estimate given. ***Please call me to authorize ANY additional treatments beyond a routine cleaning. ***

***If you cannot be reached during the procedure, medically
necessary treatments will NOT be performed.***

Dental Procedure Release

I am the owner of the above-named animal or am responsible for it. I have authority to execute this consent. I authorize the performance of the following procedures: Anesthesia, dental cleaning, polishing, and any additional treatments found to be necessary and authorized above.

Additional Procedures:

I authorize the use of such anesthetics as you deem advisable and performance of such surgical or therapeutic procedures as you determine to be indicated. The nature and risks associated with the procedure(s) have been explained to me and no guarantee has been made as to the results. I agree to indemnify and hold Golden Valley and Greenbrier Animal Hospitals harmless from and against any and all liability arising out of any of the procedures referred to above. I grant Golden Valley and Greenbrier Animal Hospitals permission to post my pet's picture, story and medical information on social media.

NOTICE-THIS ANIMAL HOSPITAL DISPOSES OF ABANDONED ANIMALS IN ACCORDANCE WITH MINNESOTA STATUTES 346.37, SUBD. 1. BY SIGNING THIS DOCUMENT YOU ACKNOWLEDGE HAVING RECEIVED A COPY THEREOF ON THE DATE INDICATED.

SIGNATURE OF OWNER OR RESPONSIBLE PERSON

PHONE NUMBER WHERE WE CAN REACH YOU ** DURING THE PROCEDURE*

I do not want my pet's picture, story or medical information posted on social media

Please check additional services you would like performed while your pet is here. There is an additional charge associated with these services. Please ask our staff for an estimate

Please list any medications your pet currently takes and whether he/she got them this morning: