Bay Animal Hospital Dental Consent Form

Bay Animal Hospital Dental Consent Form

3891 Dupont Parkway, Townsend DE 19734P: (302) 279-1082 F: (302) 279-1086
Owner Name:*
Patient Name:*
Date*

MonthDayYear
Date
The time of my pet's last meal was:*
Date & Time
Has your pet had aspirin or any other medicine within the past 48 hours?*

YESNO
List the medications:*
When was the last flea treatment given/applied?*
(If no flea treatment has not been given we will apply/give if fleas are seen on your pet.)
Does your pet have any allergies to any medications?*

YESNO
Has your pet ever had Seizures?*

YESNO
Extractions: During the dental cleaning, the teeth are evaluated, and if found to be diseased, they may require an extraction or referral to a veterinary dentist for repair. Severely diseased teeth can cause considerable pain and discomfort and are a source of infections for other organ systems (liver, kidney, lungs, and heart). The diseased teeth will require x-rays before and after extraction, or you can elect to have FULL MOUTH dental x-rays taken to determine if there is any disease below the gumline and as a baseline for future dental procedures. The cost of FULL MOUTH x-rays is $130 (does not include tooth extraction). The cost of the extractions varies depending on the difficulty and can range from $67 to $232 per tooth (including x-rays).
You must Select one of the following options:*

Yes, I give my consent for the doctors to use their professional judgement and extract any teeth necessary to maintain my pet's health EVEN IF CHARGES EXCEED THE GIVEN ESTIMATE.Yes, proceed with any indicated procedures, BUT contact me prior to performing procedures resulting in charges exceeding the given estimate.
Possible Post-Operative Care:

Oral antibiotics - at the doctor's discretion
Oral pain meds - at the doctor's discretion
Recommended oral care

Convenia injection: Pet's may have mouth pain after extractions, which can complicate giving oral medications at home. We offer a long-lasting antibiotic injection, eliminating oral antibiotics.
Convenia injection:*

Approve (if indicated)Decline (prefer oral antibiotics)
You must Select all that apply:*

I certify that I am the owner, or authorized agent.I hereby consent to and authorize the doctors and staff at Bay Animal Hospital to admit this pet, perform the dental procedures, administer medications, anesthesia, surgical procedures, tests and/or treatments that the doctors deem necessary for the health, safety and wellbeing of above patient while under their care and supervision. I certify that I am aware of the risks associated with anesthesia.I acknowledge that I am responsible for payment in full for the dental procedure and treatments at the time my pet is discharged.I understand that referral to a veterinary dentist is available. Such a referral may make available advanced endodontics, such as root canals, crowns, or other procedures that re not available at Bay Animal Hospital. Such procedures may salvage a tooth that would otherwise be extracted.
Phone Number*
Please enter a valid phone number.
Signature*

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