Small Animal Dental Admission

1

Owner Name* This field is required.

First Name

Last Name

2

Patient Name:* This field is required.

3

Make/Model/Color of the Vehicle You are Driving Today:

4

What is the best phone number to reach you TODAY to discuss your pet's care?* This field is required.

Area Code

Phone Number

5

Secondary Phone Number

Area Code

Phone Number

6

Email

example@example.com

7

What is the best way for us to contact you today?* This field is required.

Phone

Text

Email

Other

8

It is essential that we reach you by phone during your pet's dental procedure to discuss our exam findings and estimate for services. Do you have any other details about your availability by phone today that would help us contact you in a timely manner?* This field is required.

9

Who are we authorized to release your pet to other than you?* This field is required.

10

Are you leaving any items with your pet (leash/collar/etc)? If so, please describe:* This field is required.

11

Procedures to be performed today as part of our standard Dental Cleaning Package include:

Pre-Anesthetic Labwork
Pre-Surgical Examination
Pain Medication
Isoflurane Anesthesia with Intubation and Cardiorespiratory Monitoring
Routine Dental Cleaning and Polishing with Ultrasonic Scaler
Antibiotic Injection
Complimentary Nail Trim
Short Hospital Stay

12

Date of Most Recent Rabies Vaccination:* This field is required.Rabies vaccinations are required for our surgical and dental patients. A rabies vaccine will be administered to your pet at the time of anesthesia if proof of vaccine has not been provided.

13

Please indicate any additional procedures requested today:* This field is required.

Veterinary Examination for other health concern

Vaccinations

Flea/Tick Treatment (required at your expense if your pet is found to have fleas or ticks)

Intestinal De-worming

Heartworm Testing

ProHeart Injection (12 Month Heartworm Prevention) - dog only

Microchip Implantation

Nothing Additional Requested

Other

14

If requesting a Veterinary Examination, please indicate your concerns:* This field is required.Following your pet's examination, we will call you with findings and to discuss treatment recommendations and associated costs.

15

If requesting Vaccinations, please indicate your pet's needs:* This field is required.

Rabies

DHLPP (Distemper/Parvo/Lepto/Parainfluenza) - dog only

Bordetella / Kennel Cough - dog only

Feline Leukemia and FVRCP (Calici/Rhinotracheitis/Chlamydia) - cat only

No Vaccines Needed - Up to Date/Records Can Be Provided

16

Does your pet have any existing health issues we should be aware of prior to anesthesia?* This field is required.

17

Does your pet have any known allergies or reactions to medications or vaccines?* This field is required.

18

When was the last time your pet ate?* This field is required.Pet's should be fasted at least 12 hours prior to anesthesia for their safety. If your pet has eaten, your pet's surgery may need to be rescheduled.

19

What is the pet's current diet (including treats)? Please specify brand, if known.* This field is required.

20

Have you noticed any changes in your pet's appetite?* This field is required.

Increase

Decrease

No Change

21

Have you noticed any weight changes in your pet?* This field is required.

Increase

Decrease

No Change

22

Any changes in water consumption/thirst?* This field is required.

Increase

Decrease

No Change

23

Any increase in urination or accidents in the home?* This field is required.

Increase

Decrease

No Change

24

Any change in bowel movements?* This field is required.

Increase (Diarrhea)

Decrease (Constipation)

Normal / No Change

Unsure

25

Date of most recent vaccinations:* This field is required.

Use best estimate if exact date is unknown. Rabies vaccinations are required for our surgical and dental patients. A rabies vaccine will be administered to your pet at the time of anesthesia if proof of vaccine has not been provided.

26

Date of most recent heartworm test:* This field is required.

Use best estimate if exact date is unknown.

27

Date of most recent intestinal de-worming treatment:* This field is required.

Use best estimate if exact date is unknown.

28

Date of most recent labwork (CBC, Chemistry, etc):* This field is required.

Use best estimate if exact date is unknown.

29

Is your pet receiving monthly flea and tick prevention?* This field is required.

No

Yes

30

When was your last dose of flea and tick prevention given?

31

What brand of flea and tick medication are you using?

32

Is your pet receiving monthly heartworm prevention?* This field is required.

No

Yes

33

When was the last dose of heartworm medication administered?

34

What brand of heartworm medication are you using?

35

Is your pet on any prescription medications? If so, what?

36

If your pet taking any prescription medications?* This field is required.

YESNO

37

What medications is your pet taking and when was the last dosage of each medication administered?* This field is required.

38

Is your pet receiving any over-the-counter supplements (vitamins, joint support, CBD, essential oils, etc)?* This field is required.

39

Does your pet have any known behavior problems or aggression issues (biting, separation anxiety, etc) that we should be aware of prior to exam?* This field is required.An additional handling fee or sedation charge could be required. If sedation and anesthesia is declined, we may be unable to safely examine or treat your pet.

40

Following anesthesia and a comprehensive intra-oral examination, we may make recommendations for additional dental work, including dental extractions and radiographs.

We will prepare an estimate for services and call you to discuss these options. It is essential that you be available by phone so that we can discuss your pet's care with you immediately to reduce your pet's time under anesthesia.

41

Severe health problems can result from tooth infection. Often the only treatment for infected teeth is extraction. Additional fees are incurred for all dental extractions.* This field is required.

Yes, I authorize tooth extraction as needed. I understand additional fees apply.

No, do not extract any teeth.

Call or text me before extracting any teeth. If I am unavailable by phone/do not return a call within 15 minutes - proceed with treatment as the doctor deems necessary.

Call or text me before extracting any teeth. If I am unavailable by phone/do not return a call within 15 minutes - DO NOTHING ADDITIONAL.

42

We recommend dental radiographs. Dental radiographs can show us fractures and signs of infection that cannot be seen on visual exam. Additional fees are incurred for all dental radiographs.* This field is required.

Please do a full-mouth series on my pet to ensure my pet receives the best possible dental care. I understand additional fees apply.

Please perform radiographs only if the doctor deems it necessary based on my pet's oral exam. I understand additional fees apply.

I decline all dental radiographs.

43

CONSENT: I hereby authorize the doctors and staff of the Animal Clinic of West Plains to perform such diagnostic, therapeutic, and surgical procedures as described above. The nature of such services has been described to me to my satisfaction. I realize that there are risks involved with any anesthetic or surgical procedure, and that no guarantee or warranty can be made regarding the results or cure. I also authorize the hospital staff, in an emergency situation, to follow through with such procedures as are necessary for the wellbeing of my pet on a continuing basis until further communication with me. I have been given an estimate (if requested) and understand that it is an approximation of planned procedures and the final bill may be more or less than this amount. I understand that I assume financial responsibility for all services rendered and that my pet may not be released to me unless payment is received in full.

44

Signature of Owner/Agent* This field is required.

Clear

45

Date

46

Does your pet have any existing health issues we should be aware of prior to anesthesia?* This field is required.