Dental and Oral Surgery Consent Form

Pet's Name*

First NameLast Name

Who is your pet seeing today?

Your Name*

First NameLast Name

Email

example@example.com

It is imperitive that we be able to reach you in a timely manner while your pet is in the building today. Please have your cell phone listed above available and be free to talk. If you need to leave your car, leave the parking lot or will be otherwise occupied while your pet is here, please ask us about a drop off appointment.

Where can we call you at while your pet is here?*

Area CodePhone Number

Is there anyone else we can call regarding your pet while they are here today?

YesNo

Alternative Contact Name*

First NameLast Name

Alternative Contact Phone*

Area CodePhone Number

Is there any other surgery besides the dental cleaning today?

If surgical, please list surgery type (i.e. Spay, Neuter, Extractions, Mass Removal etc.)

Has your pet had any food since midnight last night?

YesNoUnsure

Has your pet been vomiting or having diarrhea?

YesNoUnsure

Does your pet have any allergies?

YesNoUnsure

If yes, please describe/provide more information

Has your pet ever had any adverse reaction to medication?

YesNoUnsure

If yes, please describe/provide more information

Please list any medications, supplements, topical treatments your pet has received in the past 72 hours and when they were last given:

When Was Your Pet's Last Dose of Flea/Tick Preventative?

Date Given (Please type N/A if not on a preventative)

What Kind of Flea/Tick Preventative Do You Use?

Name of medication - put unknown if not sure

Please note: Prairie Animal Hospital will require that a treatment will be applied at the owner’s expense to any pet with evidence of fleas, flea dirt, or ticks.

Initial Above

Is Your Pet Current On Vaccinations?

YesNoI Am Not Sure

My pet's vaccines were administered last by:

At Prairie Animal HospitalI Am Not Sure WhereOther

Does Your Pet Have A Microchip?

YesNoI Am Not Sure

Do you want your pet microchipped today? (Additional Fees Apply)

YesNo

Does Your Pet Have Known Health Concerns and/or Chronic Disease or Conditions?

If yes, please tell us more. If no, please note N/A

Is There Anything Else We Should Know About Your Pet?

If yes, please tell us more. If no, please note N/A

Are there pictures or video that would help us with our exam today?

Browse Files

Please upload if available.

Is There Any other services You Would Like To have Today?

such as nail trim, mass removal, check ears, etc

I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize treatment of my pet to be performed by Prairie Animal Hospital. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian.*

Initial

I have been advised as to the nature of this procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any sedation or anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. This risk includes serious bodily injury or death. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. If it is not emergency and the new procedure can be put off till we can get a hold of you, we will, until we can go over everything with you. I accept responsibility for any result in additional charges.*

Initial

I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital).*

Initial

In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference:

Please proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred (starting range of $150-300).Please do not proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred.

I acknowledge my choice regarding resuscitation choice for my pet as noted above.

Initial

Dental and Oral Surgery Consent Form

Authorizations