Dental Consent Form

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Enter Your Information So We Can Fetch Your Account* This field is required.PLEASE ENTER THE INFORMATION ASSOCIATED WITH THE ACCOUNT WE HAVE ON FILE.
First Name
Last Name
Phone Number
Email Address
Pet's Name
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Contact Information For Today's Procedure* This field is required.PLEASE ENTER THE INFORMATION FOR THE INDIVIDUAL WE SHOULD REACH OUT TO TODAY SHOULD THE MEDICAL TEAM OR DOCTOR HAVE QUESTIONS. THIS INDIVIDUAL MUST BE AUTHORIZED TO MAKE MEDICAL AND FINANCIAL DECISIONS FOR YOUR PET.
Contact Name
Contact Phone Number
Please Select
Please Select
Text Message
Phone Call
Preferred Method of Contact Today
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Procedure Being Completed Today:* This field is required.
Dental Cleaning
Dental Cleaning with Known Extractions Needed
Dental Cleaning with Growth/Mass Removal
Dental Cleaning with Another Procedure That Is Not Listed
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Surgical Extractions* This field is required.It can be difficult to predict if teeth need extraction when an animal is awake because tartar and movement interfere with the assessment. Severely diseased teeth can cause considerable pain and discomfort and are a source of infection for other organ systems (liver, kidney, lungs, and heart.) During the dental cleaning, the teeth are evaluated, and if found to be diseased, they may require extraction. The cost of extractions varies depending on the amount of time taken and the difficulty of the extraction and can range from $65.00 to $175.00 per tooth. Once the veterinarian has reviewed the dental radiographs and completed the oral assessment, you will be contacted at the provided number regarding additional recommendations. We will review additional costs of the recommended treatments with you and request consent. If we are not able to reach you within 10 minutes, we will complete the previously agreed-upon care plan and begin recovery. We offer the following options in the event that we are unable to reach you after 10 minutes to obtain the consent for additional necessary treatments. Please select the option that you prefer.
APPROVAL TO PROCEED AS MEDICALLY NECESSARY: I understand that I will be charged for the additional treatments that the veterinarian deems necessary for my pet. I understand that payment will be due for these treatments at the time of checkout in full.
APPROVAL UP TO A CERTAIN AMOUNT: I understand my pet is under anesthesia and would like a phone call with an updated estimate of charges and procedures. If the staff is not able to get ahold of me, I approve up to $____ in additional costs to perform the treatments needed. (An additional box will appear for you to enter the approved amount.)
DO NOT PROCEED: I understand that my pet is under anesthesia and would like a phone call with an updated estimate of charges and procedures. If the staff is unable to get ahold of me, I DO NOT WANT ANY TREATMENTS COMPLETED. I understand that in choosing this option, if I wish for my pet to have these treatments completed, I will need to return for a second anesthetic procedure at a later date. A revised plan for care and expected costs will be provided to me.
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I understand that the SBAH team will make every reasonable effort to contact me or my authorized contact regarding my pet's condition, procedure, and associated costs. If the hospital is unable to reach me or my designated contact in a timely manner, I authorize the attending veterinarian to perform any treatments or procedures deemed medically necessary for the health and well-being of my pet, up to a total amount of $ 00.00 * . This authorization remains in effect until I, or my designated contact, am able to communicate with the hospital and provide further instructions.
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Pre-Surgical Bloodwork* This field is required.I hereby consent to and authorize the performance of pre-surgical bloodwork: lab work is required and will be performed the day of the procedure if it has not already been completed at a prior appointment.
I have read, understand, and consent.
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Additional ServicesAs the owner/agent, I hereby consent and authorize the performance of the following procedures/treatments:
Nail trim (courtesy)
Microchip: We offer HomeAgain Microchips to all of our clients. Microschips are designed to help identify lost pets and reunite them with their owners. One in three pets are lost during its lifetime, and only one in ten lost pets are found. (+$75.00)
Ear Cleaning. (+$37.00)
Anal gland expression. (+$36.00)
Other
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CPR/DNR Status* This field is required.In the event that your pet should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitation efforts to be initiated until you can be contacted further and notified of their status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the veterinarian's discretion. Please select your choice below:
I agree to CPR being performed in case of arrest.
I elect a "Do Not Resuscitate" status in case of arrest.
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General Patient Information
Please Select
Please Select
No
Yes
Did your pet eat this morning?
Please Select
Please Select
No
Yes
Has your pet ever had seizures?
Please Select
Please Select
No
Yes
Is your pet currently on any medications or supplements?
Please Select
Please Select
No
Yes
Has your pet ever experienced an allergic reaction to any medications, vaccines, or anesthetics?
Please Select
Please Select
No
Yes
In the last 24 hours, has your pet experienced any vomiting, diarrhea, or coughing?
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MedicationsPlease list the medications your pet is currently taking and when the last dose was given.
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AllergiesPlease explain your pet's allergies or allergic event.
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Please notify the staff of the symptoms your pet has been experiencing. This information helps us determine the safest and most appropriate course of action for your pet's care today.
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Please Note: If fleas/ticks are found on your pet while at the hospital, they will be treated at an additional cost to you.* This field is required.
I understand and agree to the additional cost if fleas or ticks are found on my pet.
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Home Care & Recovery Acknowledgment* This field is required.I understand that follow-up care at home may be necessary to support my pet's recovery and achieve the best possible outcome. I agree to follow all discharge instructions and understand that the success of my pet's treatment may depend, in part, on the care provided by me or my designated caretaker after leaving the hospital.
I have read and understand
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Contact Acknowledgement* This field is required.I am aware that the contact listed for today's procedure must be available by telephone during the approximate time interval of 8:30 AM to 2:00 PM
I have read and am aware.
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Payment* This field is required.I agree to pay today, in full, for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. Furthermore, I understand that regardless of the outcome of the procedures, I am responsible for the payment of the procedures immediately. Please note that SBAH does NOT offer any in-house payment plans. However, for individuals preferring payment plan options, we do accept CareCredit and ScratchPay.
I have read and agree.
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Anesthesia & Surgical Risk Acknowledgment* This field is required.I have read and fully understand this Anesthesia and Surgical Consent Form. The nature of the procedure(s), as well as the associated risks, potential complications, and expected benefits, have been explained to me, and I have had the opportunity to ask questions. I understand that anesthesia, surgery, dentistry, and other medical procedures carry inherent risks, including unforeseen complications, illness, injury, or death. While Shady Brook Animal Hospital is committed to providing the highest quality medical care, anesthesia monitoring, surgical services, and dentistry, I acknowledge that no procedure is without risk and that no guarantee or warranty can be made regarding the outcome of my pet's treatment, recovery, or prognosis. I understand that the veterinarian and hospital staff will take all reasonable precautions to minimize risks and ensure my pet's safety and well-being. I acknowledge and accept these risks and understand that I am encouraged to discuss any questions or concerns regarding my pet's care with the medical team prior to the procedure. I will not hold Shady Brook Animal Hospital, its veterinarians, employees, or representatives liable for complications that may arise despite the exercise of reasonable veterinary care and judgment.
I have read and understand the above acknowledgement
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Authorization for Additional Medical Care* This field is required.I understand that unforeseen conditions or circumstances may be discovered during the course of my pet's procedure that may require additional or different services than those originally anticipated. I authorize the attending veterinarian to perform any procedures, treatments, or diagnostics deemed medically necessary for the health, safety, and well-being of my pet. I understand that the team at Shady Brook Animal Hospital will make every reasonable effort to contact me regarding significant findings, recommendations, and changes to the treatment plan. If additional procedures become necessary, I will be notified as soon as medically appropriate.
I have read and understand the above acknowledgement.
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Anesthesia Authorization* This field is required.I authorize the use of appropriate anesthetics and other medications for my pet. I understand the hospital support personnel will be employed as deemed necessary by the veterinarian.
I have read and agree.
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Pet Belongings Acknowledgment* This field is required.I understand that Shady Brook Animal Hospital is not responsible for the loss of or damage to any personal property left with my pet, including but not limited to leashes, collars, harnesses, blankets, toys, carriers, or other belongings. I acknowledge that any items I do not wish to be lost, damaged, or misplaced should be taken with me at the time of drop-off.
I have read and agree.
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Abandoned Pet Policy* This field is required.I understand that I am responsible for picking up my pet in a timely manner following today's visit or procedure. If my pet is not picked up within five (5) days and I have not contacted Shady Brook Animal Hospital to make alternative arrangements, I understand that my pet may be considered abandoned. In such circumstances, Shady Brook Animal Hospital may take any actions permitted by applicable law, including transferring ownership, rehoming, or otherwise providing for my pet's care.
I have read and agree.
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No warranty or guarantee has been offered or given to me as to the results or cure afforded by these treatments or procedures.* This field is required.
I have read and agree.
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I AM AT LEAST 18 YEARS OF AGE. I have read and understand this authorization and have the authority to execute this consent.* This field is required.
I have read and agree.
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Date* This field is required.
Date
Month
Day
Year
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Signature of Owner/Agent* This field is required.
Should be Empty: