Dental Consent Form

Please verify that you are human*

Enter your information so we can find your account.*

First NameLast Name

Phone Number*

Email

example@example.com

Your Pet's First Name*

Contact Information for Today

Please enter the information for the individual that is able to make and will be responsible for the medical and financial decisions for {yourPets}.

Contact Name:*

Phone Number*

Phone CallText Message

DentalDental with Known Extractions NeededDental with Growth/Mass RemovalDental with other procedure not listed

Surgical Extractions:

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.

PROCEED AS MEDICALLY NECESSARY: I understand that I will be charged for the additional treatments that the veterinarian deems necessary for {yourPets}. 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 {yourPets} 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 {yourPets} 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 {yourPets} 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.

Please enter the amount that you are approving:*

$00.00

I have read, understand, and consent.

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

CPR/DNR STATUS

In the event that {yourPets} 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 arrestI elect a "Do Not Resuscitate" status in case of arrest

General Patient Info

YesNo

Please explain {yourPets}'s allergies.

YesNo

Please list the medications {yourPets} receives and when the last dose was given:

I understand and agree to the additional costs that will be applied to my invoice.

Owner Responsibility

I have read and understand

Hospital and Procedural Information

Anesthesia: Pre-surgical blood tests and physical exam will enable us to assess and minimize the risk of anesthesia to {yourPets}.

Monitoring: To minimize anesthesia risk, we monitor the heart, blood pressure, respiration rates, temperature, and oxygenation.

Catheterization: For sterility, hair will be shaved over a vein on the leg so that an intravenous catheter (I.V.) can be placed. Blood pressure may lower during anesthetic procedures, and fluid therapy aids in supporting {yourPets}'s internal organ systems. It also allows immediate access to the vascular system in case of an emergency.

Pain management may be necessary for some dental procedures. The veterinarian will administer pain medications according to {yourPets}'s needs, which can be an additional fee.

Antibiotics are an additional fee and may be prescribed by the veterinarian for {yourPets}'s oral hygiene needs.

Please note: Additional surgical options will require an additional consent form to be signed.

Authorization

I have read and fully understand this anesthesia and surgery consent form. I have been advised as to the nature of the procedure(s) and the risks involved. I realize that the results cannot be guaranteed. I am aware that THERE ARE RISKS WITH ANY ANIMAL GOING UNDER ANESTHESIA and know that the veterinarian will take all necessary precautions, and I am encouraged to discuss any concerns I have about those risks with the hospital's medical staff before the procedure(s) is/are initiated:*

I have read and understand

While Shady Brook Animal Hospital provides the highest quality of anesthesia monitoring, surgical services, and dentistry, I completely understand the possibility of unforeseen complications that may occur during any associated anesthetic, surgical, or dental procedure. I fully acknowledge and understand these medical risks. I recognize that the veterinarian and hospital staff will do all that is necessary to minimize such risks. I will hold harmless Shady Brook Animal Hospital, the veterinarian, or any hospital staff member liable for any complications that may or should arise in {yourPets}'s medical treatment and care.*

I have read and understand

I understand that during the performance of the procedures/treatments, unforeseen conditions or problems may be revealed that necessitate an extension of the procedure(s) or that different procedures than those set forth may become necessary. Therefore, I consent to and authorize the performance of any such procedure(s) the veterinarian deems necessary. The staff of Shady Brook Animal Hospital will contact me as soon as medically able to inform me of any changes in my pet's condition.*

I have read and understand

Signature of Parent/Guardian*

Date*

Date