Dental Procedure Release Form

Your Name*

First NameLast Name

Your Pet's Name*

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Would you like us to text you updates during your pet's procedure?*

YesNo

It is our goal for each patient to have the safest, most stress-free experience possible. We follow the American Animal Hospital Association's highest surgical standards for the safety and comfort of your pet. All pets scheduled for general anesthesia have a preoperative exam and blood panel performed. This assesses basic metabolic function, complete blood count, and liver and kidney values. It allows us to ascertain there are no underlying issues with organ function, blood imbalances, or anemia that could cause complications. If problems are found which may significantly increase the risk of anesthesia or warrant additional care, these problems will be discussed with you prior to proceeding.
Your pet's past anesthetic history, breed, pre-existing conditions, and age are all factors used to determine your pet's personalized anesthesia protocol. Cardiopulmonary (heart and respiratory) monitoring equipment is used in all extended procedures as an added precaution. An IV solution will be administered while your pet is under to ensure proper electrolytes and hydration – this will require shaving a section of one or two legs. We will utilize the proper surgical medications to keep your pet comfortable and pain-free.

There are inherent risks with the use of anesthesia, and Duluth Animal Hospital takes every precaution to lessen these risks. Our objective is to provide the safest and most comfortable procedure possible for your pet.

After your pet is anesthetized, a veterinary technician will clean and polish your pet’s teeth with ultrasonic and hand scaling instruments the same way a dental hygienist cleans your teeth. The veterinarian will examine the teeth and gum tissue using a dental probe just as a dentist examines your teeth. A set of X-rays will be taken to evaluate your pet’s teeth beneath the gum line, and it is at this point, the doctor can fully assess your pet’s teeth and gums. These will help determine if any further treatment is indicated, as problems can often be hidden. Additional treatments may include (but are not limited to) the extraction of teeth, root planing, gingival (gum) therapy, or other surgical treatments like those provided by an oral surgeon or periodontist. Please feel free to discuss these treatments with the veterinarian.

Please select one :*

The doctor is authorized to perform any treatment necessary, including gingival therapy, root planning, removal of teeth, or other needed oral surgery as determined necessary by the veterinarian. I understand this could result in additional charges.Please call before providing any recommended procedures. Your pet will be under anesthesia at the time of the call and we ask that you be available by phone from 9AM to 4PM.

If you selected to be contacted first, but are unreachable within 10 minutes of the doctor’s call, would you like us to then go ahead with recommended procedures? (If we proceed without doing recommended procedures, your pet may need additional anesthesia and treatment at a later date).*

YesNoNot applicable

Did your pet eat this morning?*

YesNo

Has your pet had a past reaction to vaccines, medications or anesthesia?*

YesNo

If yes, please explain :

Is your pet currently taking medications or supplements?*

YesNo

If yes, please list :

Would you like your pet microchipped today? ($59.80)*

YesNo

Would you like an estimate of the fees for today's visit? Although we make every effort to adhere to any estimate given, please understand this is NOT a guaranteed quote of final cost. Actual cost may vary according to your pet's needs.*

YesNo

I understand there are always inherent risks with the use of anesthesia, and that Duluth Animal Hospital takes every precaution to lessen these risks. I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated.

I understand that the veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff has my permission to proceed with life-sustaining procedures.

I understand treatment procedures of diseased teeth are not included in the standard dental cleaning, polishing, and x-ray fees. They require additional surgical time, and injections of antibiotics and pain control medications are often required at an additional cost.

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 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.)

Although every effort to adhere to any estimate given, I understand that actual cost may vary according to your pet’s individual medical needs. Estimates are NOT a guarantee of final cost, and I will be responsible for any costs beyond the original estimate provided.

I understand full payment is due at the time of service by credit or debit card, Care Credit, or cash. Checks are not accepted.

I have requested the above services performed by Duluth Animal Hospital, and I authorize Duluth Animal Hospital to charge me for these services. I am the owner of or an authorized agent of the pet and at least 18 years of age. I have read and fully understand the terms and conditions set forth above. (signature)*

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Dental Procedure Release Form

Anesthesia & Surgical Information

More information about your pet's dental procedure today :

Your Pet's Medical History

Dental Procedure Release