Client Name:
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Patient Name:
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Best phone number to call the day of procedure:
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Are there any other procedures being done today along with the dental? (mass removal etc.)
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Does your pet have a current rabies vaccine? A current rabies vaccine certificate is required or CAHW will rabies vaccinate my pet at a $15.00 additional charge
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Yes
No
If yes, where and when did your pet receive the rabies vaccine? List clinic below. Leave blank if it was given by CAHW.
Is your pet on any medications?(other than heartworm and flea prevention)
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Yes
No
If yes, please list the medications below and when last given.
If fleas are present on your pet today, a Capstar (24 hour medication to kill fleas) will be administered at a $8.99 additional charge.
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I understand the statement above.
We can administer a 30 day flea & tick prevention for additional costs if you prefer (Please ask for details)
A complete physical exam will be performed on your pet prior to the surgical procedure. However, this may not identify all systemic or metabolic problems. For this reason, we recommend your pet have a pre-anesthetic blood panel to evaluate major organ functions prior to anesthesia.
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Yes, I approve the pre-anesthetic blood panel $98
No, I decline the pre-anesthetic blood panel at this time and accept the increased risk of complications and/or mortality and request that you proceed with anesthesia.
Bloodwork has been done within the last 30 days
During the dental procedure, if extractions or additional treatments are needed, CAHW will attempt to reach you by calling the number left above. If we cannot reach you or get a response within 5 minutes, we will proceed with one of the selected options below. The price is dependent on the extent of treatment needed and can range from $50-$1000 in addition to the dental cleaning cost.
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OPTION 1: CAHW may proceed with any and all dental extractions and treatments at owners expense.
OPTION 2: CAHW may NOT proceed with any extractions or treatment. See statement below.
If option 2 is selected above, I understand that my pet may need additional anesthetic procedures/dental care in the future at my expense.
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Yes, I understand the above statement.
I, the undersigned owner or agent of the pet identified above, certify that I am eighteen years of age or over and authorize the staff/veterinarians of Companion Animal Hospital of Waller to perform the above procedure(s) and understand that I am responsible for all charges related to this patient.
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I am 18 years of age or older
In the case that your pet were to suffer cardiac and/or pulmonary arrest (heart or breathing stops), do you authorize us to provide life-saving measures (i.e. cardiopulmonary resuscitation)? Costs of these services can be between $200-$500. If you choose to allow these procedures for your pet, we will try and contact you as soon as possible to inform you of the situation and discuss the options of how to proceed.
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Yes, I give my permission.
No, I do not give my permission.
Have you received an estimate for the procedure to be performed?
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Yes
No
If no, would you like to be provided with an estimate?
Yes
No
I understand that some risks always exist 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.
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By checking this box, I indicate that I have read and understand the statement above.
Companion Animal Hospital of Waller recommends that all patients be microchipped for identification to aid in the recovery of a lost pet. Would you like to have your pet microchipped for an additional charge of $45?
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Yes
No
Already microchipped
While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved.
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By checking this box I indicate that I have read and understand the above statement
I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions.
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By checking this box I indicate that i have read and understand the above statment
Submit
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