Dental Surgery and Treatment Consent

Dental Surgery and Treatment Consent
CLIENT/PATIENT INFORMATION:
Client Name*

First NameLast Name
Patient's (Pet) Name*
Species*
Breed*
Items left with Pet*
HOSPITAL POLICIES:

VACCINATION POLICY: Our hospital recommends that your pet be current on their distemper and rabies vaccinations. WE require that in-patients be current on rabies. Proof that a rabies vaccine have been given by a veterinarian is required at admission. If your pet is overdue for the rabies vaccine, it will be updated pending confirmation of a healthy animal.

FLEA POLICY: Pets with fleas will be treated in the clinic at additional cost.

PAIN CONTROL: All patients undergoing a surgical procedure will receive pain medication, to be given at home, to ensure their comfort.

SURGICAL FOLLOW-UP POLICY: Surgeries that are not routine may require additional visits. There may be additional fees for these visits. We do not include these fees in the surgery cost since there may be more than one recheck.
DENTAL PROCEDURE:

All patients will have full mouth radiographs evaluated during the procedure. It is often impossible to detect every possible dental issue your pet may have, until they are under anesthesia and their mouth is examined and x-rayed. Reasons for this are:

o        Lack of cooperation can impair visualization, especially of the back teeth.

o        Many periodontal problems can be detected only by probing under the gum or with dental radiographs (x-rays).

o        Dental tartar can hide underlying cavities or fractures.
If problems are detected while your pet is under anesthesia, how should they be handled? Please choose 1 below.
(Check one)*

Do whatever is needed to give my pet a healthy mouth, including extraction of diseased teeth.Contact me at the phone numbers below before doing more. ***
If I can't be reached while my pet is under anesthesia:*

Perform whatever procedures are needed.do ONLY what I have authorized.
ANESTHESIA SUPPORT SERVICES:

When general anesthesia is used for your pet's dental or other procedure, it is not without risk. To maximize their care and safety we may recommend your pet receive the supportive services below. Depending on your pet's age, some of these we may require. Complete descriptions of each are provided below.

Keep in mind these services are at an additional cost, estimates are available upon request.
Pre-Anesthetic Testing (choose 1): Blood work to access your pet's internal health before general anesthesia.*

Chem 10: Highly recommended for all pets under age 6.Chem 17: Highly recommended for all pets, for a more complete screening, and REQUIRED for all pets over age 6.I DECLINE the pre-op blood testing that is recommended, but please perform the procedure.
IV Catheter/Fluids (choose 1): Support for kidney function and immediate intravenous access in case of an emergency. REQUIRED for all dental procedures.*

I understand that this service is required for the well-being of my pet to receive his/her dental procedure today.
Anti-Nausea Relief: Relief for nausea and/or vomiting associated with anesthetic procedures. May also help patient return to eating faster. **This medication may be REQUIRED if there are extractions and for some other surgeries.*

YES - I want my pet to have this medication for potential nausea or vomiting associated with anesthesia.NO - I do not want my pet to have this medication for potential nausea or vomiting associated withanesthesia.
EKG (choose 1): Recommended for ALL pets, to access your pet's heart health

YES - Please perform an EKG on my pet, to access his/her heart healthNO - I DECLINE an EKG at this time
Microchip ID (choose 1): Best time for microchipping! Includes chip, implantation & 1st year of service through Home Again

YES - I want my pet microchipped while under anesthesiaNO - I do NOT want my pet microchipped while under anesthesia
ADDITIONAL SERVICES OFFERED:

Most services are less stressful and more comfortable under anesthesia.
Please check ALL that apply.

Update vaccinesHeartworm TestFIV/Felv TestEar cleaningNail TrimAnal Gland ExpressionMICROCHIP ID: *** best time for microchipping ***Heartworm PreventionFlea & Tick PreventionOther - (please provide explanation below)
If "Other" was selected above:
CONSENT TO TREATMENT:

I am the owner or agent for the owner of the above-described animal and have the authority to execute this consent. I hereby authorize Heartland Veterinary Clinic to perform the procedure(s) listed above. I understand that during the performance of the foregoing procedure(s), unseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) that are set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarian’s professional judgment. I also understand that I will be responsible for full payment of services at the time my pet is discharged from the hospital.

I have read and understand this authorization and consent, and being of legal age (18), I hereby consent and authorize this hospital and its veterinarians and staff to perform the agreed to procedures.
- I have been advised as to the nature of the procedure(s) and/or surgery and the risks involved.
- I accept that anesthesia always involves some element of risk to my pet.
- I understand that every precaution is practiced to ensure the safety of my pet before, during, and after the procedure.
ESTIMATES AVAILABLE UPON REQUEST
EMERGENCY CONTACT NUMBERS (1)*

Area CodePhone Number
EMERGENCY CONTACT NUMBERS (2)*

Area CodePhone Number
Date*

MonthDayYear
CLIENT SIGNATURE*

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Please contact us with any questions at (540) 434-3903.
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