Dental Cleaning & Procedure Admitting Form
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Pet's Name:
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Any vomiting, coughing, sneezing or diarrhea?
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Yes
No
Did your pet eat this morning?
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Yes
No
Is your pet allergic to any drugs?
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Yes
No
If yes, what?
Has your pet had any accident or illness in the last 30 days?
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Yes
No
Is your pet currently on any medications?
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Yes
No
If yes, what?
Any specific problems to be checked?
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Yes
No
If yes, what?
Any dental hygiene products used on regular basis?
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Yes
No
If yes, what?
Are vaccinations current?
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Yes
No
No, please update
Elective Procedures to be Done Under Anesthesia
These are simple procedures that do not greatly increase sedation/anesthesia time and therefore can be provided for a fee (avoiding additional sedation that would be required for the separate procedure)
Select any additional procedures:
Comprehensive Physical Examination
Ear Cleaning
Routine Toenail Trim or Dremmel
Express Anal Glands
Brush out/ Clip Hair Mats
Remove Skin Growth (Does Require Extended Anesthesia Time)
Extraction & Other Procedures Consent/ Waiver
Sedation is required before a thorough examination can be completed. The condition of each tooth must be evaluated before a decision is made as to the best course of treatment. Although no one likes surprises, it is impossible to give an accurate estimate before sedation. It is more economical to complete dental procedures during the initial visit and sedation rather than having to schedule another appointment with additional anesthesia. Please select the appropriate option below:
Choose ONE Option:
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Please perform whatever procedures & extractions are required at this time.
Please perform whatever procedures & extractions are required up to a specific amount. ($300 to $500 is average)
Please call me during anesthesia with an estimate if any additional procedures are needed. Do not proceed without authorization. Since pet will be under anesthesia, doctors will wait up to 15 minutes for a callback.
I would like to stage any procedures needed after the cleaning. I understand that will require an additional episode of anesthesia.
Phone number where I can be reached today while pet is under anesthesia:
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Pre-Anesthetic Screening and In Operative Procedures
Like you, our greatest concern is the well being of your pet. A physical examination has been performed on your pet. However, many conditions, including disorders of the kidneys, liver, heart & blood cannot be detected without blood lab screening. For these reasons, we require pre-anesthetic blood work before anesthesia. All patients are monitored for heart rate and blood oxygen levels during procedures. Patients over the age of 5 years will have an IV catheter placed and maintained on IV fluids during their procedure.
Preferred type of medication to give at home (if needed)
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Liquids
Tablets/ Capsules
Owner Release to Cliftwood Animal Hospital
You are to use all reasonable precaution against injury, escape, or death of my pet. I understand that all sedation/anesthesiainvolves some minimal risk to my pet, but you will not be held liable in any manner whatsoever or under any circumstances inconnection therewith as it is thoroughly understood that I assume all risks. I have read the foregoing and agree.
Signature
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Clear
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Submit
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