Oral Health Procedure Consent Form

Client Name*

Patient*

Sex*

Date*

Date

DOB*

Species*

Phone Number*

Please enter a valid phone number.

Email*

Age*

Breed*

I certify that I am the owner, or authorized agent for the owner, of the above animal. I hereby consent to and authorize the doctors and staff at this veterinary practice to admit this pet, perform the above described procedures, and administer medications, anesthesia, surgical procedures, tests, and/or treatments that the doctors deem necessary for my animal's health, safety, and well being while under their care and supervision. I have been advised of the nature of the procedures and the potential risks and benefits. I understand that veterinary medicine is an inexact science and that no guarantee of successful treatment can be made.*

I have been informed of the fasting requirements for anesthesia. The time of Fred's last feeding was:

Date and time*

Date

Hour MinutesAM/PM Option

Is your pet on any medications?*

YesNo

If yes, please list the name of the medication(s) and when the last dose was given:

Has your pet been ill recently?*

YesNo

If so, please briefly describe symptoms and indicate date/time of last symptoms:

Should unexpected life-saving emergency care be required and the attending veterinarian be unable to reach me I approve emergency resuscitation.*

Yes (CPR)No (DNR)

I acknowledge that I am responsible for payment in full for the above procedures and treatments at the time my pet is discharged.*

Standard pickup time is between 4-5PM due to the nature of hospital safety procedures and anesthesia recovery. I understand that Mill Creek Animal Hospital closes at 5PM.*

Your pet is undergoing an anesthetic procedure today. Rest assured that advances in anesthesia, anesthetic monitoring, and surgery have made procedures safer with a low rate of complications. Nevertheless, some obscure conditions can be detected only by diagnostic testing. Because of this, we require pre-anesthetic screening testing prior to surgical procedures. If this has not been performed prior to today's procedure(s), it will be performed today prior to anesthesia.*

I understand that if my pet is not up-to-date on their core vaccines*, they will be vaccinated today unless otherwise authorized by the veterinarian.

(* Felines: Rabies and FVRCP/ Canines: Rabies, DAPP, and Bordetella)

In pets, the teeth cannot be thoroughly studied until the pet is anesthetized. Once under anesthesia, your veterinarian will perform a complete oral exam and carefully check teeth and gums. Because 60% of the tooth structure is below the gumline, we will take dental x-rays to get an accurate diagnosis of the condition of your pet's teeth and jawbone. During this comprehensive oral assessment, your doctor may find one or more teeth that need to be extracted for health reasons.*

We realize that you may not have planned for these additional services. We must be able to reach you by phone if we find any issues in order to recommend a treatment plan and seek authorization to proceed (cost estimates will be provided). We will make every reasonable attempt to reach you. However, procedures requiring anesthesia are time-sensitive and provide a narrow window of time in which to reach you.*

Should any unforseen dental procedures be necessary in the veterinarian's professional judgement:*

I prefer that you proceed with all necessary dental procedures. If I cannot be reached by phone please proceed with treatment. *The veterinarian will call to discuss diagnostic findings and treatment options.*I prefer to be called before any additional procedures, other than emergencies. If I cannot be reached please leave a voicemail. **Pets will be woken up 15 minutes after attempt to reach owner.**

Your signature confirms that you have read this information and understand it. At any time during your pet's treatment, you may ask for an update of services and fees. We appreciate your confidence in our medical team.*

Clear

Client Name (Printed)*

Pet's Name*

Date*

Date

Phone Number (Primary Contact)*

Please enter a valid phone number.

Phone Number (Secondary Contact)*

Please enter a valid phone number.

Oral Health Procedure Consent Form

Extent of Dental Services Desired