Teeth Cleaning & Anesthesia Consent Form

Owner's Name*

First NameLast Name

Client ID No.*

Email*

example@example.com

Phone Number*

Alternate Phone Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Pet's Name*

Pet's ID No.*

Species*

Breed*

Weight*

Age*

Sex*

Procedure*

Like you, our greatest concern is the well being of your pet. Your pet will be anesthetized today and because we know your pet is a valuable member or your family, we want the procedure to go as safely as possible. We use the latest in anesthetic and monitoring techniques, however, no procedure can be completely guaranteed.

We require a preanesthetic blood profile to help us place your pet in a low risk category.

Initial if yes YES, Please run a mini screen recommended up to 8 years of age (10 tests).
Initial if yes YES, Please run a full survey recommended over 8 years of age (17 tests).

Is your pet current on heartworm preventive? (Dogs only)*

YesNo

If yes, what type?

If your pet is not current or does not have a current negative test on file , we will perform a heartworm test on your pet today for anesthetic risk purposes. Cost $20.00

Has your pet ever had any type of seizure activity?*

YesNo

Please tell us if your pet has had ticks in the last 12 months. An additional test may be recommended.*

NoneA fewMany

Teeth cleanings require that antibiotics go home with the animal for several days. The usual cost for antibiotics is $20-$40 depending on the weight of the animal. Depending on the severity of periodontal disease in your pet's mouth several additional procedures may be required.

If any teeth are loose and roots are infected, we recommend extracting them. If deep pockets are present in the gums surrounding the teeth, we will place an antibiotic gel in the pockets. If a tooth looks questionable as to whether
or not it has an infected root or needs extracting, then dental x-rays may be needed.

Like you, we want to provide the best care for your pet. We do not enjoy extracting teeth, but often due to dental disease it is medically necessary to do so.

By agreeing to this anesthesia form, you agree to let our veterinarians
make that judgement call on extractions. If you would like an estimate, we would be more than happy to provide one for you.

There are several products you can use at home to help reduce the progression of dental disease. Mouth rinse, a water additive, and/or CET brand rawhide chews may help keep your animal's mouth clean and healthy. Please ask a veterinary assistant about these items.

If we are removing a mass from your pet do you want to have the it sent to the diagnostic lab to check for cancer? (Histopathology)*

YesNo

Would you like an elizbethan collar for your pet to keep them from licking their incision?*

YesNo

While your pet is sedated it is also an excellent time for us to perform other services if needed. Is there anything we can check for you?

I understand all of the above and assume all financial responsibility for this animal. I understand there are always potential risks when using anesthesia or performing surgery on an animal. I understand there is a possibility of death with any anesthetic procedure.

By checking this box I agree that all charges rendered are due at the time of service.

I agree

Signature*

Date*

Date