Dental Cleaning Consent Form Name* First Last Email* Phone*Secondary PhonePet Name* Pet Species*DogCatWould you like your pet microchipped during their procedure(s)?* Yes No Already Microchipped The following are included in our STANDARD DENTAL CLEANING. Hospitalization. (CBC and Chemistry). Anesthesia (- including pre-medications, induction agent, gas anesthesia, monitoring, ECG and Pulse Oximeter). Full mouth dental radiographs. Ultrasonic enamel cleaning above and below the gum-line & Rotary Polish. Pedicure. Fluid therapy: IV Catheter or subcutaneous fluids - To support kidney function and blood pressure during anesthesia, we include fluids administered either through an IV catheter or subcutaneously. IV catheter does leave a small shaved spot on a front leg. Complicated dental extraction: prices may vary I have been shown a treatment plan* Yes No, please contact me regarding a treatment plan I would like to receive a treatment plan via* Phone Email Extent of Dental Services DesiredShould any unforeseen dental procedures be necessary and desirable in the veterinarian’s professional judgment. Please select one of the options below:* I prefer that you proceed with all necessary dental procedures. I prefer to be called before any additional procedures, other than emergencies. If I cannot be reached, I authorize you to proceed with all necessary dental procedures. If I cannot be reached by phone, I do not authorize any unforeseen dental procedures. I understand this may result in needing to reschedule additional dentistry services at a later date. By initialing here, I understand I may need to reschedule additional dentistry services at a later date if the doctor decides the procedure is not able to be performed in the scheduled time.* InitialsI understand I may need to reschedule additional dentistry services at a later date if the doctor decides the procedure is not able to be performed in the scheduled time. Antibiotics and/or Pain relief medications: Will only be sent home if deemed necessary by the doctor and price varies. I understand that during the performance of the foregoing procedure(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or different procedure(s) than those 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 authorize the use of appropriate anesthetics and other medications and I understand the hospital support personnel will be employed as deemed necessary by the veterinarian. I have been advised as to the nature of the procedures or operations and the risks involved. I realize that results cannot be guaranteed. By initialing here, I am indicating that I understand the above paragraph* InitialsI understand that if my pet is kenneled overnight, there are no staff members present after hours.* InitialsIs your pet currently on any medications?* Yes No Signature*Date* MM slash DD slash YYYY Please select how you would like us to contact you* Please call the above number or text a different number or email when surgery is complete. Preferred method of contact Initial* CAPTCHA Δ
