Dental Cleaning Surgery Consent Form

Client Name *

Patient Name *

Patient Age *

Breed *

Sex *

Date of procedure *

Preferred Contact Number on Surgery Day *

Phone Call *

Phone Call Text

Is your pet currently on any medication? *

Yes No

If yes, please list all medication and how often it is administered

Dental Cleaning and Oral Exam Pricing

0-24lbs	$280.00
25-49lbs	$313.75
50-74lbs	$336.75
75-99lbs	$363.50
>100lbs	$383.75

Our base dental prophy cleaning and polishing fee includes the following:

Pre-anesthetic assessment prior to the procedure. A current full wellness exam is required within 90 days for all patients prior to their dental cleaning.
Pre-anesthetic ECG screen IV Fluids
Gas anesthesia using isoflurane with respiratory, oxygen, and heart rate monitoring
Ultrasonic scaling and polishing of the teeth
Oral exam under anesthesia by the doctor
Nail trim (only if requested for cats)

Please review each of the listed options and check yes or no for each one:

Pre Anesthetic Blood Screen $149.00-$279.50- pricing based on age *

Yes No

A 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 highly recommend a pre-anesthetic screen for all patients. This is required for pets 7 years of age and older within 90 days of the procedure. *

I acknowledge that if my pet is 7 or older this will be performed

Extractions and Medications

Extractions are performed only if the doctor determines they are needed. We need pre-authorization so that we do not need to keep your pet under anesthesia longer while trying to reach you by phone. The cost can vary greatly due to the difficulty and type of extraction and additional procedures and medications required due to extractions. It is difficult to predict if or how many teeth may need to be extracted until teeth have been cleaned and a proper oral exam under anesthesia can be performed. Please schedule a dental consultation for a general estimate prior to your pet's procedure if you have not received one and are concerned about extractions.

I authorize extractions or oral surgery deemed necessary: *

Yes No

Full Mouth X-Rays $183.00-$268.00 (pricing based on weight)

Dental X-rays are always recommended as it allows us to see the root health of the tooth and what lies below the gumline. This helps us to better determine if a tooth may or may not need to be extracted compared to visual examination alone.

I would like full mouth x-rays to be performed: *

Yes No

Please read the following:

I understand that some risks always exist with anesthesia and surgery and that I am encouraged to discuss any concerns that I have with the attending veterinarian about those risks prior to the procedure.

I understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies and I acknowledge that life-saving procedures will be performed in the case of an emergency

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.

I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed such as radiographs, re-check examinations, and additional surgery due to post-op complications. These are more likely to occur when there is failure to comply with the aftercare instructions that will be provided on the day of surgery.

I have read and fully understand the terms and conditions set forth above.

Signature *

Clear

Date *

Please remember to not feed your pet 8 hours prior to drop off for surgery. Keep water available