FMC- Feline DENTAL Consent Form

Client's Name*

First NameLast Name

Email*

example@example.com

Phone number where you can be reached day of surgery. *

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cat's Name*

Breed*

Color*

Sex*

Female/Spayed/Male/Neutered

Weight (LB)

Surgical procedure(s) to be performed:*

When was food last given?*

I, the undersigned owner or agent of the pet identified above, authorize the staff of The Feline Medical Center to perform the above procedure(s).

I understand that some risk always exists with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated.

In case of unforeseen emergencies, does the staff have your permission to proceed with life sustaining procedures?*

Yes, I give my permission to perform CPR and other life-sustaining measures and understand I am responsible for the cost of these procedures (additional fees apply).No, I do NOT give my permission to perform life-sustaining measures (Do Not Resuscitate).

Has your cat had any previous surgeries?*

NoSpay / NeuterDentalOther

Has your cat shown any signs of illness in the last 2 weeks? If yes, please explain. *

Is your cat currently taking medications? If yes, then please list the medications including dosage. *

A thorough examination of each tooth is seldom possible before your pet is anesthetized and the plaque is removed from the tooth. It is only at this time a proper decision can be made as to the best course of treatment. Extraction may be necessary for the health of your pet and treatment must be done in a timely manner while your pet is under anesthesia. Take home pain medications and/or antiboiotics will be prescribed as the doctors deems necessary.

Dental Extractions*

Call me first- I will be available by phone today to discuss further treatment cost for my pet.I understand and accept any additional costs that are incurred. Please proceed with any treatment or extractions that the doctor deems necessary. I understand the cost of extractions are not included in Paw Plan dental cleanings.

Photo Consent*

Yes, I authorize FMC to take pictures of my pet's teeth today to be used in the future to promote dental health on social media and/or the website (no identifying information will be shared).I do not authorize the sharing of any pictures of my pet's teeth today.

A microchip can be inserted under the skin between the shoulder blades to aid in recovery and identification of a lost or stolen pet. The cost is $102.00 and includes the lifetime registration of the chip. The microchip will automatically register with your account details on file.

Microchip*

Yes, please insert a microchip while my pet is asleep.No, I do not want my pet microchipped today.My pet is already microchipped. Please check my pet's chip today.

While your pet stays with us we require him/her to be up to date on vaccinations and to be free of external parasites such as fleas or ticks. If your pet is found to be unvaccinated or if fleas or ticks are found the proper vaccines/medications will be given at the owner's expense.

Optional Additional Services to be performed while your pet is under anesthesia. Please select any and all optional services that you would like performed- additional cost applies.*

Toe nail trim $30 + taxNail caps applied (front only) $75 + taxI would like SANOS dental sealant applied (*Ask us for details) $70No additional services

I have read this consent form in its entirety. While I accept that all procedures will be performed to the best of the abilities of the hospital staff, I understand that no guarantee or warranty has been made regarding the results that may be achieved.

Authorizations and Acknowledgment*

I authorize The Feline Medical Center to perform all necessary surgical procedure(s) to my pet.I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment instructions and follow-ups as needed.I release The Feline Medical Center for any responsibility in case of an accident, illness, or injury.

Owner Release*

I assume full responsibility for any additional expenses incurred before, during, and after the surgical procedure is performed, such as progress exams, radiographs and/or additional surgery due to additional findings or post-op complications.I understand that if I no-show for the scheduled surgical procedure or cancel less than 48 hours prior to the scheduled surgical procedure, I will incur an additional fee of $100.00.

Client/Agent Signature

Date Signed

Date

Feline Dental Consent Form

Patient Information

Medical Data

Acknowledgment & Authorization