Countryside - Authorization for Dental Treatment Anesthesia Form

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Client Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Date of Procedure* This field is required.
Date
Year
Month
Day
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Pet Name* This field is required.
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As owner (or agent for the owner) of the pet described above, I authorize Countryside Veterinary Hospital to perform any diagnostic, therapeutic, anesthetic, emergency, and surgical procedures necessary for treating and maintaining my pet’s health and well-being. While I expect all procedures to be performed to the best of the staffs’ abilities, I realize the hospital makes no guarantee or warranty regarding the results. If my animal should injure his/ her self, escape, fail to eat, become ill, or die, I will not hold Countryside Veterinary Hospital and/or its employees responsible. I expect the hospital to use reasonable precautions to ensure my pet’s safety, and I agree to pay in full when the pet is discharged. Initial *
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Please check and initial each category below. I give my consent to Countryside Veterinary Hospital to perform the following procedure/care: Dental Cleaning* This field is required.
At a doctor’s discretion, a Heartworm Test may be completed at a charge of $44.99.
All pets being dropped off for services must be current on Rabies, Distemper/Parvo, and Bordetella. I understand that I will be liable for the charges for getting my pet up to date on any vaccination needed.
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Additional Treatments * This field is required.
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Post Operative Pain Medication and IV Fluids are Included with every Dental Procedure. * This field is required.To ensure your pet’s health and safety during surgery, we recommend blood work to check for liver problems, infections, and other health problems that may be missed with the physical exam.
Chem 17, electrolytes and CBC $158.96
PCV/Chem 10 $77.14 (Required for patients 8 years and older)
No, I decline the additional Bloodwork
All pets age 8 and older are required to have a PCV/Chem 10 at a minimum. A Chem 17, Electrolytes and CBC provides more in depth health information compared to a PCV/Chem 10.
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I would like for the following options to be performed while my pet is here today:
Dremel Toenails *
Microchip Implant *
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Please list all medications that the pet is currently taking.* This field is required.If your pet is not currently taking any medications, please put "None".
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Multiple Pets: Please initial if you would like for your pets to be kept in a cage together (Initial) *
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Dentals* This field is required.Due to the condition of your pet’s teeth, it may be necessary to do further treatments after the dental cleaning is complete. These treatments can include but not limited to Clindoral and Extractions.
Yes I give permission for additional treatments to be done while under anesthesia
I would like a call before further treatments
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If we try to call and are unable to reach you do you want us to * This field is required.
Go ahead with the recommended procedures.
Wake up my pet up from anesthesia understanding that there will be unresolved medical issues and that there will be additional costs to address these issues at a later date.
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I understand that I am responsible for the additional cost of the options I have requested above. * This field is required.
Initial
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Telephone number where owner/agent can be reached* This field is required.
Area Code
Phone Number
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Preferred method of communication* This field is required.
Text
Call
Email
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Pets over the age of eight are required to get a panel of blood work done.* This field is required.
Initial
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Signature of owner/agent* This field is required.
Clear
Should be Empty: