CANINE DENTAL PREPARATON FORM

Owner / Agents Name (Print)

Patient's Name

Surgical or Medical Procedure

Date of Procedure

Date

Please complete this form no later than 3 days before your pet’s scheduled surgery.

NAIL TRIM: We can perform our most accurate nail trim while your pet is sedated. This service is complimentary when you bring your pet in for surgery. COMPLIMENTARY

INTRAVENOUS CATHETER AND FLUIDS: For increased anesthetic safety, placed before surgery for delivery of fluids and/or medication to maintain blood pressure throughout the procedure. A local anesthetic is used to minimize any discomfort that may be associated with catheter placement. INCLUDED

PRE-SURGICAL VITAL SIGNS CHECK: Prior to beginning your pet’s procedure today we check their vitals to screen for any recent developments that would change our medical plans. COMPLIMENTARY

(Please read carefully and mark one choice for each item. These may not have been included in your estimate.)

If you have any questions about your options or why a procedure is recommended please ask an ITAH staff member.

DENTAL RADIOGRAPHS: A surprising number of dental problems (abscesses, root resorption, etc) can occur under the gumline and go unidentified even after careful examination. Routine full mouth dental radiographs allow us to make the best treatment decisions for each tooth. The cost of any additional anesthesia time required is included.

Do you want us to perform a full-mouth dental radiograph on your pet? (Cost - $99)

Yes No

ORAVET BARRIER SEALANT: We can apply OraVet Barrier Sealant as the last step in your pet’s dental cleaning. OraVet creates an invisible barrier that prevents plaque and tartar forming bacteria from attaching to the teeth for up to 2 weeks. At that point, your pet’s gums will be healed and ready to start a home dental care program.

Do you want your pet to have a sealant application? (Cost - $15)

Yes No

PRE- ANESTHETIC TESTING: Since anesthetics are removed from the body through the kidneys and/or liver, it is important to know that internal organ function and blood values are within normal limits. This is best done before the day of the procedure for the most information at the best value. Additionally, an ECG screen read by telemedicine consultants before your pet's procedure helps us check for arrhythmias that can't be heard with a stethoscope or other subtle heart hearth changes that we need to know about before anesthesia.

Do you want your pet to have a pre-anesthetic ECG screening? (Cost - $45)

YES NO

Do you want your pet to have a pre-anesthetic blood screen? (Cost - $82)

YES NO Already Done

ANTI-NAUSEA TREATMENT: Improve your pet’s recovery with a 24 hour anti-nausea dose of Cerenia® to prevent vomiting and get them back to eating and acting normally as quickly as possible. This drug is a great benefit!

Would you like your pet to be protected from nausea with Cerenia®? Cost based on weight: [up to 50lbs = $42] [over 51lbs = $64]

YES NO

TEMPSCAN® MICROCHIP IDENTIFICATION: Prepare for the unexpected... HomeAgain companion animal retrieval system permanently identifies your pet. The applied microchip and unique identification number used by Animal control and shelters can be used to reunite you and your pet through a national registry of your choice. The new microchips also report internal body temperature when scanned! This price includes lifetime registration in the Home Again database (we pay the $20 registration fee for you). You may change your information at any time at www.HomeAgain.com or by calling 1-888-466-3242.

Do you want your pet to be permanently identified with a microchip? (Cost - $ 50)

YES NO Already Done

This section applies to the entire form: I’ve read the preceding page and selected the options I am most comfortable with. Where noted, I understand that ITAH doctors may require services that I have not requested for the safety of my pet. I agree to pay for services rendered. I have read the foregoing, understand what it says and agree.

Owner/ Agent (Signature)

Clear

Date

CANINE DENTAL PREPARATON FORM

INCLUDED PROCEDURES:

OPTIONAL, BUT RECOMMENDED PROCEDURES:

SIGNATURE REQUIRED