Dental Consent Form Westlake

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Please enter a valid phone number.

Secondary Phone

Please enter a valid phone number.

Is it okay to text this phone number with updates or reminders? *

Yes No

Animal Name *

Animal Species *

Animal Breed *

Animal Age *

Animal Sex *

Male Neutered Male Female Spayed Female

Animal Weight *

What procedure will your pet be having?

Will you be fasting your pet after 10 PM the night prior to surgery? *

Yes No

Is your pet eating and drinking normally? *

Yes No

Please explain

Has your pet experienced any of the following?

Coughing Sneezing Vomiting Diarrhea

Please explain

Have you noticed any changes in your pets energy level or attitude? *

Yes No

Please explain

Is your pet currently on any medications? *

Yes No

Please list each one your pet is currently on, as well as date last given, dosage amount, and when the next dose is due

If your pet is due for vaccinations, would you like them administered at the time of surgery? *

Yes No

Would you like us to administer them today?

Yes No

Dental Procedures:

Dental Cleaning is the procedure to remove alculus (hardened tartar) from the crown of the tooth as well as under the gumline using an ultrasonic scaler. Once the teeth are cleaned, they are polished to ensure they are smooth.

Dental Radiographs are necessary to identify and diagnose dental disease under the gumline. These are performed during every dental cleaning.
Doxirobe Gel is an antibiotic that in some cases can be placed under the gum line of a tooth with a periodontal pocket in an effort to preserve the life of the tooth.
Composite Sealants can protect chipped or fractured teeth from sensitivity if the nerve is not exposed. In most cases if the pet needs a composite sealant we can do this at the time of the dental cleaning. If the nerve is exposed, we will recommend extracting that tooth as it is very painful for the pet.
Extractions are performed when the veterinarian has determined that a tooth is severely diseased and/or broken and needs to be removed for the health and safety of the pet. We make every effort to save a tooth if it viable and only recommend extractions when they are medically necessary.

We often identify dental problems after our patients are anesthetized that we were unable to identify while they were awake during a previous exam. While we do save all viable teeth, sometimes composite sealants, doxirobe gel, or extractions are necessary. It is imperative that we have a number where we can contact you at anytime during the procedure.

If we are unable to contact you with an updated treatment plan please select one of the following:

I authorize any treatment the doctor seems necessary. If I am unable to be contacted regarding any unforseen treatment, I will provide an estimate value not to be exceeded before dropping off my pet. Do not go over the high end of the procedure estimate.

Would you like to sign up for a courtesy nail trim? *

Yes No

Would you like a microchip placed during the procedure? *

Yes No Pet already has one

Please list any personal belongings coming into the clinic (please note that we do not recommend any belongings come into the clinic with your pet including bedding, collars, leashes and harnesses as we cannot guarantee it will be returned).

Please check each box to acknowledge each statement below: *

I understand that some risks always exist with anesthesia and/or surgery Should some unexpected life-saving emergency care be required, Westlake Animal Hospital staff has mypermission to provide such treatment and I agree to pay for such care. I understand that an estimate of the costs for veterinary services will be provided to me. I understandthat this is an estimate only and that the cost of surgery or treatment may vary. I agree to assume full responsibility for the balance of all services rendered with cash, check, or a creditcard at the time my pet is discharged from Westlake Animal Hospital. If I neglect to pick up my pet within 15 days of the above date, you may assume that the pet isabandoned and Westlake Animal Hospital may assume ownership of pet. I understand that Westlake Animal Hospital is not staffed between the hours of 7:00pm and 7:00am. I understand that a 50% deposit is required for all treatments and/or surgeries. If my pet is requiring anovernight stay I understand that all charges will be closed out and processed each night on the credit card Iprovided. Please place my deposit and daily charges on credit card number on file. Checking this box indicates receipt of estimate.

The best telephone number to reach out regarding my pets care today is *

Please enter a valid phone number.

Signature *

Clear

Dental Consent Form

Client Details

Animal Details

General Health Screening