Dental Procedure Consent Form

Client *

First NameLast Name

Email*

Patient

Name*

Is your pet allergic to any medications?

YesNo

If Yes*

Any history of seizures and/or previous anesthetic problems?*

YesNo

Is your pet currently on any medications other than the pre-op care package?*

YesNo

If yes, what is he/she taking?" "What dose and last given?*

Is your pet vomiting?*

YesNo

Does your pet have diarrhea?*

YesNo

Would You like us to update any past due vaccines during your pet's visit? Current Rabies Vaccine is mandatory, the vaccine will be given if no proof of current vaccine is provided.*

YesNo

Is your pet on a heartworm preventative?*

YesNo

If no, would you like us to do the necessary bloodwork to get started on a preventative?*

YesNo

Is your pet currently using flea prevention products?*

YesNo

If no, would you like us to send home flea preventative today?*

YesNo

Is your pet microchipped?*

YesNo

If no, would you like to have us insert one?*

YesNo

Procedure To Be Performed Today

We will be placing an IV catheter to administer fluids throughout the procedure for maintenance of proper blood volume and faster recovery.

Would you like us to perform screening bloodwork on your pet before anesthesia to evaluate the overall health of your pet's organs to assess their ability to process anesthesia? Please note that if your pet is 2 years of age or older blood work is mandatory. *

YesNo

Would you like us to perform a urinalysis on your pet to evaluate kidney and bladder health?

YesNo

Would you like us to use post-operative laser therapy to accelerate healing?

YesNo

Extraction Consent

If the dental estimate is exceeded during the procedure and additional extractions are deemed necessary:*

I give permission to the Doctor and RVT to extract teeth today as deemed medically necessary in accordance to the treatment plan.I DO give permission for the doctor and RVT to continue the procedure and exceed the agreed upon estimate up to $500.I DO NOT give permission for the doctor and RVT to go beyond the agreed upon estimate.

Social Media Consent

I hereby authorize Mid-Valley Veterinary Hospital to use and take photos of any/all of my pets. I understand these photos may be used for publications including websites, social media, staff training, educational or entertainment purposes.*

YesNo

CPR/DNR

In the event that Patient Name* should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of Patient Name* status?

By consenting to this service, you are also acknowledging that certain charges will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion.*

CPRDNR (“ Do Not Resuscitate”)

Contact Information*

I wish to be contacted by phone when my pet is recovering from surgeryI wish to be contacted by text message when my pet is recovering from surgery

PHONE NUMBER(S) WHERE YOU CAN BE REACHED TODAY*

If you cannot be reached at the phone number provided above, we will not proceed with the procedure or treatment. This can cause delays in pick-up times, and our ability to treat your pet. You will be still be charged for any services performed.

Lizzie’s Law

In 2019 California passed Lizzie’s Law which mandates all veterinarians to provide clients with key information every time a drug is prescribed. Which of the following options would you like in regards to any medications going home?*

Verbal consultationWritten consultationDecline consultation

Owner Release And Consent

I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. My signature below certifies that I am over eighteen years of age.

MVVH Orland, Inc., doing business as Mid-Valley Veterinary Hospital, will use all reasonable precautions against injury, escape, or death of your pet.

I have been informed that there are certain risks and complications associated with sedation, anesthesia, and/or any operation/procedure and that the risks/complications have been explained to me. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before the procedure is initiated.

I authorize the use of appropriate anesthesia and pain relief medication as needed before, during or after the procedure. I have been informed that there are risks associated with the use of any medication.

The nature of these operations or procedures has been explained to me and I understand what will be done. I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. I have been encouraged and given the opportunity to discuss any questions I may have regarding my pet's medical care and my questions have been answered to my satisfaction. I agree to hold Mid-Valley Veterinary Hospital harmless, in the absence of negligence, in connection with these procedures.

In the event complications arise and I cannot be immediately contacted at the below-listed phone number, Mid-Valley Veterinary Hospital is directed to make the decision(s) it deems best for my pet.

I accept that my financial obligations remain regardless of the outcome. I have read the foregoing, understand what it says, and agree.

A DEPOSIT OF 50% OF THE COST OF THE TREATMENT PLAN IS DUE AT THE TIME OF PATIENT DROP OFF FOR ALL SURGERIES AND EMERGENCIES. I ACKNOWLEDGE THAT ANY REMAINING BALANCE IS DUE AT TIME OF DISCHARGE.

Signature*

Date*

Date

Dental Procedure Consent Form

Patient

HISTORY

Procedure To Be Performed Today

Extraction Consent

Social Media Consent

CPR/DNR

Lizzie’s Law