Complete Dental Cleaning Consent Form

Please complete the following form prior to the day of your pet's dental procedure. If you have any questions or have further information to provide, please feel free to e mail us at wac@williamsburganimalclinic.com or call us at 413-268-7738.

What day is your appointment for:*

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pet's Name*

What phone number can we reach you at if we have questions during your pet's dental procedure?*

If we can not reach you at the number listed above, what is an alternative number we can call?*

Visual inspection of the oral cavity does not always identify bone loss or hidden tooth decay. Sometimes x rays are required to determine whether a tooth can be saved or needs to be extracted.*

I authorize dental x rays if indicated.No I do not authorize dental x rays.

I understand that decisions regarding dental treatment will need to be made while my pet is under anesthesia. If additional x rays, extractions or treatments are indicated what should we do:*

Proceed with all indicated x rays, treatments and extractions.Call with an updated plan. If I am unreachable, proceed with all indicated extractions or treatments.If I am unreachable. DO NOT exceed the estimate.

The nature of the procedure and risks involved has been explained to me and I realize results cannot be guaranteed. I am also aware that unforeseen events resulting from the procedures will not relieve me from any obligation to all reasonable costs incurred regarding this pet.*

YesNo

I understand that during my pet's procedure I must be reachable at the phone number I provided above. I understand that if I am unable to be reached during my pet's procedure and I have decline or placed a monetary limit on pre approved treatment this may results in the recommendation for an additional procedure with additional costs.*

YesNo

I also understand that by declining extractions, this may results in an additional procedure with additional costs.*

YesNo

In order to preserve the health of your pet's teeth, a fluoride treatment is recommended while your pet is under anesthesia. This treatment helps strengthen the protective enamel coating on every tooth. The cost is $25.00*

Yes, please treat my pet's teeth with Fluoride.No. Do not treat my pet's teeth with fluoride.

The Companion Animal Parasite Council and the CDC recommend testing kitten's and puppy's feces for parasites 2-4 times in their first year of life and twice a year thereafter. We recommend that while your pet is anesthetized today we obtain a fecal sample to check of parasites. The cost is $49.07*

Yes, please check my pet for parasites.No. Do not check my pet for parasites.

We recommend the DATAMARS Microfind microchip ID system for every pet. A chip can be safely and Painlessly implanted while your pet is anesthetized. The cost is $48.00.*

Yes, please microchip my pet.No, Do not microchip my pet.

Pre anesthetic testing is required to ensure that your pet is in a low risk category prior to anesthesia. The latest technology has enabled us to run safe and accurate blood chemistry panels minutes before anesthetic induction. These tests are similar to those your own physician would run were you to undergo anesthesia. In addition, the results of these tests will serve as reference values should your pet become ill.

Blood Profile 1: Healthy patients under 2 years of age.

Cost: $110.00

Generally used for spay/neuter surgeries or brief procedures of young healthy pets.

Blood Profile 2: Healthy patients 2-5 years of age.

Cost: $158.00

Generally used for brief diagnostic or surgical procedures on healthy pets.

Blood Profile 3: Patients over 5 years of age or patients with questionable healthy status.

Cost: $198.00

Generally used for major surgical/dental procedures of for patients with chronic healthy issues.

We will gladly provide you with a written estimate of the cost of these procedures if requested.

Please type the date*

Please type your name to confirm the information provided on this form is correct*

Is your pet on any medications?*

YesNo

Please list any medications your pet is currently taking. Please include the medication name, strength, dose and last time it was administered.*

I understand that any pets found to have fleas or ticks will be treated with an appropriate flea and tick product at the owner's expense.*

Yes

Additional services requested:*

What "other" services would you like us to provide?

Has your pet eaten after 11pm last night?*

YesNo

I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at time of release, and that a deposit may be required.

Primary Phone*

Please enter a valid phone number.

Secondary Phone

Please enter a valid phone number.

Signature*