Surgery Consent Form - Canine Dentistry 8yrs and Younger

Surgery Consent Form - Canine Dentistry

PETCARE Animal Hospital
If you are scheduled to have multiple procedures done at one time (ex. dental with a mass removal) - do NOT fill this dental consent form out. This consent form is purely for dentals ONLY. Thank you.

THIS FORM DOES NOT GET YOU IN CONTACT WITH THE SURGERY COORDINATOR - IF NEEDING TO SCHEDULE A PROCEDURE, PLEASE GO TO WWW.TINYURL.COM/PETCARE01
Client Information
Name - Primary Point of Contact*

First NameLast Name
Phone Number - Primary*
Please enter a valid phone number.
Email*
example@example.com
Name - Secondary Point of Contact (Optional)

First NameLast Name
Phone Number - Secondary
Please enter a valid phone number.
Patient Information

Information on the Patient Scheduled for the Procedure
Pet's Name*
Gender*

FemaleMaleUnknown
Breed*
Dental Consent and Estimate

Please select any services you wish to be performed at the time of the dentistry
My Products
prevnext( X )
Canine - DentistryYou will receive an itemized receipt at the end of the procedure. A Dentistry includes: Pre-anesthetic blood work (CBC/CHEMISTRY), IV fluids during and after the procedure, full-mouth radiographs, clean/scale, polish, and fluoride.EXTRACTIONS/MEDICATIONS/BONDED SEALANTS ARE ADDITIONAL!
$730.00



Microchip
$65.00



Heartworm TestThe Heartworm preventative for your pet is ADDITIONAL to this fee $
$50.00



Cone CollarCone collars are NOT automatically sent home, as not every pet requires one. If your pet has a history of licking or hyperactivity, please consider a cone collar.
$21.50



Total

$0.00
If additional services (extractions/medications/bonded sealants) are needed: what are we allowed to do?*

Do Whatever is Necessary, Regardless of Price - No Call Needed Prior to PerformingDo Whatever is Necessary, Regardless of Price - A Call Needed Prior to Performing - Proceed if Not Reached$1000 Additional - No Call Needed, Unless Exceeds $1000$1000 Additional - A Call is Needed, Proceed if Not Reached$650 Additional - No Call Needed, Unless Exceeds $650$650 Additional - A Call is Needed, Proceed If Not Reached$350 Additional - No Call Needed, Unless Exceeds $350$350 Additional - A Call is Needed, Proceed if Not ReachedNo Additional Permission is Granted - Must Contact for Additional Permission. I Understand if I Do Not Respond within 10 Minutes of Contact, My Pet will be woken up and they will NOT receive these services.
I hereby authorize PETCARE Animal Hospital to perform the procedures listed on this estimate. I acknowledge that I am the owner or the agent of the owner of the animal described above. I understand that medical procedures, anesthesia, and/or surgery pose a risk to my pet, regardless of health status. The risks can range in severity from nausea to sudden death. In the event of unforeseen complications, I give permission for the doctors and staff to take reasonable measures in treating my pet and waive all liability of the doctors and staff in the performance of all procedures undertaken on behalf of my pet.

This is an ESTIMATE of anticipated fees and is NOT a GUARANTEE of final fees. Each patient is different and final treatments will often vary to a certain extent from anticipated procedures. In some cases the services actually performed can vary substantially in scope and expense from what is initially projected.

Unless otherwise specified in writing, each estimate is NOT "ALL-INCLUSIVE". Additional fees may result from the treatment of complications, recheck examinations, additional medications, tests or x-rays, or additional procedures. These are often unpredictable and cannot be accurately estimated at the beginning of treatment.

I authorize the staff doctors to make use of such equipment and personnel as they shall designate. I understand that medical procedures, anesthesia, and/or surgery pose a risk to my pet, regardless of health status. In the event of unforeseen complications, I give permission for the doctors and staff to take reasonable measures in treating my pet and waive all liability of the doctors and staff in the performance of all procedures undertaken on behalf of my pet.

I agree that my pet must have proof of vaccinations (Dogs - DA2PPV / Bordetella / H3N8 Influenza / Rabies, Cats - FVRCP / Feline Leukemia Virus / Rabies) or will be vaccinated at my cost today, provided that their health does not in the judgment of the doctor preclude vaccination.

I understand that any prescription medications dispensed are not returnable per Utah State Law.

I understand that a deposit shall be required before the treatment and/or hospitalization of my pet, and that any reduction or waiver of said deposit shall not alter the requirement to pay in full for all services at the conclusion of my pet's treatment.

I agree to pay a finance charge of 1.5% per month on any balance (or $2 service fee, whichever is greater) if this account is not paid in full at the conclusion of the initial care provided by PETCARE Animal Hospital Inc. I agree that I shall pay any costs required to collect on this account (up to 33.3% of outstanding fees), whether by legal action or collection agency.

You will pay the $200 bloodwork at the time the blood work is drawn. It will then be removed from the overall total / estimate. The remainder is due at the time of the dentistry.
Signature*

Clear
Post-Operation Discharge Instructions
Diet: You may give some water tonight (when you arrive home) - go slowly and make sure that your pet holds it down. If they hold it down, please start food slowly (approximately 7pm this evening) and work back up to normal amounts over the next 24 hours.

Medications: If your pet was sent home with any medications, please start these at 7pm this evening - following the instructions on the bottles. Please let us know if you are having difficulty giving any of these medications.

IV Catheter Care: One or multiple legs have been (partially) shaved for the IV catheter placement. Please check this site(s) several times a day to make sure your pet has not irritated it by licking at it. If licking begins, please use a cone collar or a long-sleeve t shirt to prevent licking.

Due to the fact your pet has been on IV fluids for most of the day, they WILL need to urinate more often than normal. Please allow access to outside more frequently, otherwise an accident may occur in the house.
If your pet was sent home with the pressure / vet wrap still on its leg, please remove immediately.

Dental Care: If you pet received any extractions, root canals, or bonded sealants - please offer them a soft diet (whether you feed them canned food or soak their regular dry food in water for 10 minutes before offering it to them) for the next 10-14 days. We offer a no-charge dentistry recheck TWO weeks after their procedure if you would like the veterinarian to check the healing process (if they received extractions/sealants).

Many pets do not show pain in the same way that humans do. Extractions can be painful and some pets will still not show that they are in pain. As a result, we do not believe that our patients should have to 'prove' to us that they are painful; we want them to be as comfortable as possible at all times when they are recovering.

Please make sure that your pet receives ALL of their doses of pain medication.

Please do not give your pet any chew toys or rawhides, etc. for the next 10-14 days.

Some pet's will have stitches (and others will not). Any stitches, if present, will dissolve in about 2-4 weeks and do not need to be removed.

Special Instructions:

Thank you for allowing us to provide your pet with the best care possible. They were a wonderful patient and we wish them a quick and easy recovery. If you have any questions or concerns, do not hesitate to call or text us at 801.302.9061.
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Surgery Consent Form - Canine Dentistry

Client Information

Patient Information

Dental Consent and Estimate

Post-Operation Discharge Instructions