Dental Consent Form - All Creatures Veterinary Services

"*" indicates required fields

Owner's Name*

First Last

Phone Number (ICE)*

Patient’s Name:*

Breed*

Age:*

Species*

Dog

Cat

Sex*

Male

Female

Please list any medications not prescribed by All Creatures Veterinary Services that your pet is currently taking, including over the counter medication.

PLEASE NOTE: ALL PATIENTS WILL RECEIVE A CAPSTAR UPON ARRIVAL IF FLEAS ARE PRESENT*

I understand

ALL PATIENTS HAVE TO BE UP TO DATE ON ALL VACCINE*

I understand

Teeth Extractions : Many pets require sedation/general anesthesia before a thorough examination can be completed. The condition of each tooth must be evaluated before a decision is made as to the best course of treatment. Although no one likes surprises, it sometimes is impossible to give an accurate estimate before sedation. Therefore, please select one of the following options:

Please perform whatever procedures and extractions are required at this time.

Please do nothing more than the requested dental cleaning procedure at this time.

Please call me after the exam with an estimate if any additional procedures are needed. Do not proceed without authorization.

secified amount*

Additional Surgical Options:

Laser Therapy: One time treatment after surgery to promote wound healing and decrease pain/inflammation. The cost is $10*

Yes, I ACCEPT

No, I DECLINE

I.V. Catheter: All patients will receive an IV Catheter to help increase the safety of the procedure(s). This will allow instant access for emergency medications in the event an emergency occurs.*

I understand

Pain Medication: All Surgery patients receive a pain medication injection that is included in the price of their surgery. However, that price does not include additional pain medication to be sent home with the patient (which you, the owner, will administer).*

Yes, I have elected for my pet to receive the optional pain medication at the approximate cost of $20-$40, which will vary based off weight range.

Pre-Anesthetic Bloodwork: Pre-Anesthetic bloodwork is recommended to screen for existing disease that could be made worse by anesthesia or that could interfere with a pet’s recovery from anesthesia. Bloodwork is highly recommended if your pet is 7 years or older.*

I understand

Please complete the mini panel of bloodwork you are recommending prior to surgery on my pet at the additional cost of approximately $110.00 depending on the patients specific needs.*

Yes, I ACCEPT

No, I DECLINE

Please complete the full panel of bloodwork you are recommending prior to surgery on my pet at the additional cost of approximately $247.00 depending on the patients specific needs.*

Yes, I ACCEPT

No, I DECLINE

Microchip: Microchips are a form of identification that cannot be lost or stolen. The microchip that our clinic uses is injected under the skin of your pet. It is traceable by Google and by microchip readers at veterinary clinics or shelters. We recommend micro- chipping your pet during surgical procedures due to the large size of the needle used to implant the chip.*

Yes, I would like for my pet to have a microchip at the additional cost of $52.

No, I would not like my pet to have a microchip.

I understand that some risks exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:

The reasonable medical and/or surgical treatment options for my pet
Sufficient details of the procedures to understand what will be performed
How my pet will recover
The most common and serious complications
The length and type of follow-up care and home restraint required
The estimate of the fees for all services

I understand the above statement*

I understand and agree

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. I agree to assume financial responsibility for the cost and provide payment via cash, credit card, or check at the time my pet is discharged from the hospital.*

I understand and agree

Please select one:*

Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff has my permission to provide such treatment and I agree to pay for such services.

Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff does NOT have my permission to provide such treatment and I agree to pay for such services.

If I desire that my pet have supervision when this facility is closed, I elect to transfer him/her to a local emergency clinic where overnight veterinary supervision is available at my expense.*

I elect

I do NOT elect

I have read and understand the nature of the above procedure(s) and give my consent to proceed. I understand that all estimates are approximate and therefore not guaranteed.*

I have read and understand

As the owner of this pet, I hereby give my consent to veterinarians of All Creatures Veterinary Services to perform the above stated procedure.*

I give my consent

Signature*

Date*

MM slash DD slash YYYY

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