Dental Surgery Release Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Pet Name*

Pet Species

DogCatOther

Birthdate or Age

Breed

Was this dental procedure recommended by one of our doctors.*

YesNo

Is your pet current on vaccinations*

YesNo

Is your dog on heartworm prevention?*

YesNoNot applicable

If no, we recommend a Heartworm test and starting prevention

Yes, run the test $51.50No, I do not want a heartworm test

Has your cat been tested for FeLv/FIV*

YesNoNot applicable

If your cat has not been tested we recommend a test.

Yes, run the test $55.50No, I do not want an Felv/FIV test

Any coughing, vomiting, or diarrhea noted?*

YesNo

Has your pet eaten this morning?*

YesNo

Has your pet been ill or injured in the past 30 days?*

YesNo

Is your pet allergic to any medication?*

YesNo

If your pet is allergic to a medication, what is that medication?

We require a blood panel prior to dental procedures to help detect any internal problems that may not be evident upon physical examination. Which blood panel we do is based on your pet's age.

Up to 6 years of age Chem5/CBC. This checks blood levels and kidney and liver values. $91.75

6-10 years of age Chem 10/CBC. This checks blood levels and a slightly larger chemistry panel. $104.00

Over 11 years of age Chem17/CBC/Electrolytes. This checks blood levels, our most comprehensive chemistry panel, and electrolytes. $179.25

Additional procedure(s) done while your pet is under anesthesia? If so what?

Microchip and Registration

Yes, place a microchip while my pet is asleep $61.75No, I do not want a microchip

Post-surgical Laser Treatment to help alleviate pain and inflammation. Laser therapy is NOT recommended for any tumor removal surgeries.

Yes, I want my laser therapy for additional pain control $14.50No, I do not want laser therapy

I am the owner or agent for the above described animal and have the authority to execute this consent and authorization of the above named surgery (s). I understand that during the performance of the procedure(s) unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s), or even different procedure(s) as necessary and desirable in the exercise of the veterinarian’s professional judgement. I have been advised of the nature of the procedure(s), as well as the risks involved, and also realize that the results cannot be guaranteed.
I additionally authorize the use of appropriate anesthesia, pathologist examination of excised tissue as deemed appropriate by the veterinarian, and the administration of the medications, and understand that hospital staff will be utilized as deemed necessary by the veterinarian. I have read and understand this authorization and consent.

Signature of owner or agent*

Date of Signature

Date

Phone Number where we can reach you during the surgery*

Please enter a valid phone number.Format: (000) 000-0000.

Dental Release Form