DENTAL CONSENT FORM
Your pet is scheduled for a dental cleaning and polish, which requires general anesthesia. At this point, we have discussed if we expect there to be extractions (removal of teeth) with you. This will be reviewed again when you drop off your pet, and on the estimate.
Your Name
*
First Name
Last Name
Pet's Name
*
What is the best phone number to reach you at while your pet is hospitalized with us?
*
Format: (000) 000-0000.
Email
*
example@example.com
Is there a secondary person we can contact regarding your pet if we are not able to reach you?
Yes
No
Alternative Contact Name
First Name
Last Name
Alternative Contact Phone Number
Format: (000) 000-0000.
Has your pet had any food, water, or treats since 10:00pm last night?
*
Yes
No
Unsure
Has your pet had any of the following in the last 24 hours?
*
Vomiting
Diarrhea
Coughing/Sneezing
I am uncertain
Does your pet have any allergies?
*
Yes
No
Unsure
If yes, please describe/provide more information
Has your pet ever had an adverse reaction to medication?
*
Yes
No
Unsure
If yes, please describe/provide more information
Please list all medications, supplements, or topical treatments your pet has received in the past 24 hours. Please document below how much of each medication/supplement and when they were last given:
*
Is There Anything Else We Should Know About Your Pet?
If yes, please tell us more. If no, please note N/A
FINANCIAL RESPONSIBILITY
I have reviewed the estimate for my pet's procedure today:
Yes - I received and have reviewed the estimate
No - I never received an estimate
We do our best to create accurate estimates. Unfortunately, once your pet is anesthetized we are able to get a much better evaluation of their teeth. On occasion, we discover there is a tooth that needs to be removed due to it being broken, decay, or other unexpected causes. In the event that I cannot be reached during the procedure and do not return the doctor's phone call within five minutes:
I authorize the doctor to proceed with any recommended treatments without verbal permission, but only after the doctor attempted to contact me. I understand that these additional procedures/treatments will incur an additional cost but are being recommended as they are in the best interest of my pet.
I decline any additional recommended procedures. I understand that my pet will be woken up from anesthesia and if I decide to do the recommended procedure/treatment after they have woken up, these things will be pursued at a later date.
*Only applicable if your pet is getting a lump or tumor removed. We recommend histopathology in order to identify the type of tumor and level of aggressiveness. It typically take 10-14 days to receive the results of this additional testing. Histopathology for a single mass costs $200; there are additional costs for each additional mass.
Yes, I would like the mass sent off for histopathology.
No, I do not authorize histopathology
Send out samples if doctor recommends
If your pet does NOT have a microchip, would you like us to insert one? This is associated with an additional cost of $54.00.
Yes
No
Not Applicable
AUTHORIZATION
In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedures today. Any known risks will be discussed with you. However, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference:
*
Please proceed with life-saving measures. I will accept responsibility for all costs incurred.
Please proceed with life-saving measures. I will accept responsibility for all costs incurred, up to $500
Please do not pursue CPR, nor any life saving measures.
I acknowledge my choice regarding resuscitation choice for my pet as noted above.
Initial
I verify that I am the owner (or authorized agent for the owner) of the above named pet. I authorize treatment of my pet to be performed by Wickham Animal Hospital & Boarding. I authorize the use of anesthesia and other medications as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian.
*
Initial
I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time that my pet is released from the hospital. I understand that, in the event my pet will be hospitalized overnight, there is no staff overnight (pets needing special care may be referred to a 24 hour hospital).
*
Initial
Signature
*
Submit Form
Submit Form
Should be Empty: