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Dental Cleaning Form

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    Medical Agreement

    I, being of legal age and responsible for the animal described above, have the authority to grant the Low Cost Spay/Neuter, Inc. staff members, volunteers, or agents my consent to receive, transport, prescribe for, and treat and/or perform surgery upon the animal named above. I agree that I have not or will not claim any right of compensation from any of them, or file action by reason of such sterilization or attempted sterilization of such animal or any consequences related thereto.

    I understand that the surgery presents some hazards and that injury to, or death of, such an animal may conceivably result, for there is some risk in the procedure and the use of anesthetics and drugs used in providing this service. In the course of treatment, if a life-threatening condition occurs which requires immediate medical attention and the owner cannot be contacted, the attending veterinarian may, at his/her discretion, perform life-saving procedures without the owner's verbal consent. I consent to these procedures and agree to pay reasonable additional charges, if any. I understand that some factors significantly increase surgical risk, including but not limited to pregnancy, being in heat, diseases such as FIV, Feline Leukemia, Heartworms, and underlying or preexisting medical conditions. 

    I understand that if my animal is pregnant, the pregnancy will be terminated at surgery. I further understand that as long as, in the opinion of the attending veterinarian, the animal is an acceptable

    surgical candidate, sterilization procedures will be performed regardless of the animal's sex or medical condition (including pregnancy or menstruation) and an additional fee will be applied. I also understand that the veterinarian can refuse to perform any procedure on any animal for any reason at any time. Such refusal is at the sole discretion of the attending veterinarian. In the event of a post-operative surgery-related complication, I understand that follow-up veterinary care must be done at a veterinary clinic of my choice and cost accrued will be my sole responsibility.

    I certify that my animal is in good health and has had no food since 9:00PM the evening prior to surgery. I understand that the LCSN has the right to refuse service to any animal to whom surgery is deemed a health risk. I understand that the LCSN will not be performing a complete health examination on the animal before surgery is performed.

    If an animal is left at the clinic beyond 5pm without prior arrangements, an abandonment fee of $25.00 will be charged and abandonment procedures will be initiated as outlined by Arizona state law. I further understand that I will be fully responsible for all accrued charges until the animal is removed from the clinic, or considered to be abandoned by Arizona state law. I understand that Low Cost Spay/Neuter Clinic does not maintain 24-hour observation of animals in its care and that all emergency services needed after-hours will be referred to any local veterinarian in the Kingman area.

    • My signature on this form indicates that any questions I have regarding risks or other issues associated with sterilization and other procedures have been answered to my satisfaction.
    • Please present questions and concerns to medical staff in the exam room.


    Responsible Person Signature    
    Date    Pick a Date    

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    Please initial where applicable 

    I would like to purchase pain medication for my animal. A 24HR DOSE OF PAIN MEDICATION IS REQUIRED. Pain management can speed healing and improve quality of life during the recovery time!
    FELINE:
       1 day $6: One 24HR dose of pain medication given after surgery
        3 day pain medication injection: $15 (Recommended for ALL older cats, especially those with mild dental disease or stomatitis)
    CANINE:
        1 day: One 24HR dose of pain medication given after surgery - $6 small dog - $8 large dog >25lbs.
       3 day pain medication: $15 (9 oral doses of Tramadol after surgery to go home) Liquid medication can be requested! Recommended for ALL dogs with mild to severe dental disease.
    Other services/products available:
       Vaccinations:
          
      
         
        
          

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       Cerenia Injection or Tablets — This medication combats nausea and disorientation that can occur with anesthesia. This is highly recommended for animals over 3 years old, small dogs, and ALL females. The price is determined by weight—injections for smaller pets are $11 and tablets are for larger dogs, which averages about $1 per pound.
       Dental X-Rays: Full Mouth X-Rays — $40-$60 (depending on size of pet) Recommended for all pets that are receiving dental work. This can determine exactly which teeth need to be pulled as this finds dental disease before it is seen on the outside of the tooth. This extends the life of a dental procedure, as we are able to extract ALL diseased teeth during the procedure. This is required for cats diagnosed with stomatitis that are expecting full mouth extraction.
       Sealant - $40 –This is a protective sealant coating that is applied to all teeth after surgery. This can extend the life of the dental procedure by deterring plaque for 6 months to a year. This is recommended for all small dogs, especially those with severe dental disease. 
        Propofol Package - $40 for dogs less than 30lbs, $60 for dogs over 30lbs – This is an upgraded anesthetic in comparison to traditional anesthesia. This drug is metabolized very quickly, resulting in faster recovery for your pet, less stomach upset, and normally become active within 15 minutes of surgery. This is recommended for ALL dogs, especially older and smaller pets, and is required for pets over age 8.
       Post-Dental Laser Therapy — $10 Once performed on your pet’s extraction site(s), laser therapy reduces risk of infection by increasing circulation, which greatly improves healing time, and reduces pain and inflammation of the gums. Highly recommended for ALL dental surgeries! 

       Microchip – $25.00 – Includes FREE at home online registration!   
       Nail Trim – $5 w/surgery
       Anal gland expression — $8.00 
       Ear cleaning (non-diagnostic) — $10.00
       Ear Mite Treatment for Cats (Must get ear cleaning w/medication) $10 – If severe, may need to go home medication for $5 each tube, or can bring back to clinic for free treatment. 
       Flea/Tick Preventive — Single Dose (1 month supply)
    Dogs – 2.5-95lbs $13 96+lbs $15
    Cats - $11
       Basic Deworming – Strongid – hookworms, roundworms $5 for pet < 30lbs, $7 pet 31-50lbs, $10 for 50- 100lbs+ Drontal Plus – hookworms, roundworms, AND tapeworms (Recommended for cats) $12-15 for a cat, $13-45 for dogs (calculated by weight)

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    Thank you for choosing LCSN Clinic to perform your pets dental today. Included with your pets dental is the injectable anesthesia (ketamine/valium mix), and inhalant anesthesia (up to 1 hr.), scale and polish, dental probing exam, and dental block (if teeth are extracted). After cleaning, a full oral exam is done including dental probing to determine if there are any abscessed teeth that need to be removed. Please read below and choose any other options you would like to include with your dental. Feel free to ask any questions you may have at check in for your dental and bring this form with you for check in.

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    Options:

    REQUIRED All dentals are required to receive 1 day of pain medication that is administered before the procedure. We also have the option of a 3 day pain medication, especially recommend if teeth are pulled.
    Would you prefer?  
        1 day pain med $6/$8 (>25#)
        3 day pain med $15,
    if so     liquid (large dogs liquid option not available)
       pill

       Dental xrays $10 per xray. We are one of the few facilities in Kingman that offer dental xray in order to prolong the life or your pets dental. Probing your pets teeth lets us determine abscesses that are farther along in the disease process but many times there are periapical abscessed which are only at the root part of the tooth. With dental xray’s we can visualize these abscesses and can pull the tooth at this time versus having an abscessed tooth in 3-8 months. Each xray depending on the size of dog can cover 2-4 teeth. We recommend xrays with all dental and to do full arcade xrays for most dogs/cats can range from $80-100. This can extend the life of the dental for over a year and can save the owner in the long run with less dentals in the future. This is recommended for small breed dogs/cats, and animals that have extensive dental disease. 
       Propofol package - $40 <30#, $60 >31#. This is an upgraded anesthetic in comparison to our traditional anesthesia. We require this with any animal over 8 years of age. This drug is metabolized very quickly, resulting in faster recovery for your pet, less stomach upset, and they normally become active within 30 minutes of surgery. This is recommended for ALL older and smaller pets. 
       SANOS Sealant $40 – This is a protective sealant coating that is applied to all teeth after the cleaning. This can extend the life of the dental procedure by deterring plaque for up to 6 months to 1 year. This is recommended for all small dogs, especially those with severe dental disease. 
        Clindaoral - After cleaning the teeth, periodontal pockets can be found during our probe exam. If there is moderate pocketing, instead of pulling the tooth we are able to administer an oral gel material that will decrease pocket depth and decrease discharge in pocket in future. Clindoral is a periodontal filler that contains 2 percent clindamycin hydrochloride in a biodegrading gel matrix that releases clindamycin over seven to 10 days from a single application. This will allow for the gumline to attach to the tooth and possibly save the tooth for a longer period of time.
       Post –Dental Laser Therapy - $10 – Once performed on your pet’s extraction site(s), laser therapy reduces risk of infection by increasing circulation, which greatly improves healing time, and reduces pain and inflammation of the gums. Highly recommended for all dentals with extractions. Other valuable additions:
        Cerenia injection/tablet – This medication combats nausea and disorientation that can occur with anesthesia. This is highly recommended for animals getting significant dental work. The price is determined by weight –injections for smaller pets are $15, larger pets tablets which average around $1 per pound. 
       Vaccines - Rabies $10, Da2PP(Parvo, 5in1) $15, Bordatella $10, FVRCP $15, Feline Leukemia $15
       Microchip $25 – Includes FREE at home online registration!
       Nail Trim $5 w/surgery
       Ear Cleaning (non diagnostic) $10
       Anal gland expression $8

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    Veterinary Dentistry has three very basic goals:

    1. Every pet should have a comfortable mouth.
    2. Infection and inflammation in the mouth should be eliminated or minimized.
    3. There should not be growths or tumors occurring in the mouth.  

    Most people wake up every morning and have no worries that they will have a comfortable mouth that day. Unfortunately, it is estimated that 93% of pets in America wake up every morning with oral discomfort in the mouth. That is why Dr. Sim is so passionate about veterinary dentistry. Helping pets and educating our pet parents about how to maintain comfortable mouths in their pets is our mission.

     
    There are a number or reasons why dental X-rays are essential for your pet and why they are necessary in order for our dental team to adequately care for your pet. The visible part of the tooth is called the crown. When we look at a tooth, we cannot see the interior of the crown or the roots, so we are only looking at about 25% of each tooth. We also cannot see the jawbone or the periodontal ligament that holds the tooth in place. X-rays are the only way we can detect problems in these areas. 


    Eighty percent of dogs and seventy percent of cats have periodontal disease by age 3 years. It is the most common disease in pets, even exceeding fleas in incidence. Periodontal disease is a serious gum infection that damages the soft tissue and destroys the bone that supports teeth. Periodontal disease can cause tooth loss or worse, an increased risk of serious health problems. This disease occurs below the gum line where it cannot be seen by just looking. To visualize bone loss below the gums, X-rays are essential. If the bone loss is not too advanced, Dr. Sim can often save teeth suffering from periodontal disease, but it is impossible to know if an affected tooth can be saved without an X-ray showing the extent of the damage.

     
    One extremely important difference between dogs and cats vs. people is that pets seldom show obvious outward signs of periodontal disease or oral pain. Animal behaviorists believe that hundreds of years ago, the animals in the wild learned that showing pain or weakness encouraged predators to attack them and caused healthy animals to feel superior and eat available food first. Thus, it is well documented that our domestic pets seldom demonstrate symptoms of the throbbing pain associated with many dental problems. Every time we have our teeth cleaned, the human hygienist asks if we are having any sensitivity or pain. Our ability to answer that question greatly reduces the necessity for people to have full mouth x-rays. Pets simply cannot tell us.

     
    Cats tend to hide medical symptoms even more than dogs do. In university studies, it is estimated that 51% of cats develop “cat cavities” which are termed resorptive lesions. Resorptive lesions are very common, they are blatantly painful, and many lesions can only be identified with X-rays.

     
    Without taking X-rays of the mouths of domestic pets, it is estimated that even dental specialists miss 20% of the problems that are present If we didn’t X-ray your pet’s mouth, we would have to tell you, “We did an 80% job of eliminating pain today.” X-rays are that important!

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    Here is a list of some of the things we identify using dental X-rays:

    • Periodontal disease
    • Missing teeth – impacted, retained roots or cysts
    • Injured or fractured teeth
    • Dental cavities
    • Pulpitis/pulp necrosis
    • Tooth resorption
    • Baseline for comparison in the future
    • Post-extraction to be certain of complete removal of roots
    • Endodontic procedures such as root canals
    • Oral Tumors – bone involvement  

    Below are some X-rays which identified problems typically found in our patients. To show you everything that we can identify with X-rays, we would have to show you hundreds, but I have chosen a few interesting examples.

       

      

     

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    DENTAL EXAM AND PROCEDURE RECORD

    Date Pick a Date    
    Pet Name       
    AGE       
    Diagnosis:       
    Cleaning:
    Routine        
    Extended       
    X = Extraction O = Missing

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