Complete Dental Cleaning Consent Form

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:*

MonthDayYear
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
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?*
Format: (000) 000-0000.
If we can not reach you at the number listed above, what is an alternative number we can call?*
Format: (000) 000-0000.
I authorize dental x rays if indicated.No I do not authorize dental x rays.
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.
YesNo
YesNo
YesNo
Yes, please treat my pet's teeth with Fluoride.No. Do not treat my pet's teeth with fluoride.
Yes, please check my pet for parasites.No. Do not check my pet for parasites.
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*

MonthDayYear
Please type your name to confirm the information provided on this form is correct*
YesNo
Please list any medications your pet is currently taking. Please include the medication name, strength, dose and last time it was administered.*
Yes
Nail TrimAnal Gland ExpressionMicro chipNo additional servicesOther (Please list other services in next box)
What "other" services would you like us to provide?
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.Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Signature*

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