Dentistry/Anesthesia Consent Form

Pet's Name*

Owner's Name*

First Last

This procedure will include preparation, anesthesia, monitoring, catheterization and fluid support, and pain management. If you would like a detailed explanation of each area covered under the procedure, please see a staff member. An information form is also available for your convenience.Once your pet is under anesthesia, your veterinarian will perform a complete oral exam and carefully check your pet’s teeth and gums. During this comprehensive exam, your veterinarian may find one or more teeth that need to be extracted for health reasons. Radiographs may be required to obtain an accurate diagnosis of the condition of your pet’s teeth and jaw bone.

Based on the veterinarian’s recommendations, the following dental procedures and services may be required:

Extractions (per tooth)
Single root: $13.25
Double root: $26.00
Triple root: $51.50
Surgical extraction: $83.50 - $125.00
Radiographs: $58.00 (per view)
Extensive Dental Treatment: $91.50 (additional)

Should any unforeseen dental procedures be necessary in the veterinarian’s professional judgement (please check one of the following):*

I prefer that you proceed with all necessary dental procedures.
I prefer to be contacted before any additional procedures. If I cannot be reached, I authorize you to proceed with all necessary dental procedures.
I do NOT authorize any additional dental procedures.

Please check any of the following you would like included with this procedure:*

Pre-Anesthetic Bloodwork: $97.00 (in house, day of procedure) We will perform a full physical examination on your pet before administering anesthesia. However, we highly recommend a pre-anesthetic blood panel be performed. This will ensure that your pet is in a low risk category for anesthesia by screening for medical problems which may not be evident physically but could affect your pet’s recovery from anesthesia and/or surgery.
Heartworm Test: $46.50 For canine pets, a current negative heartworm test (within the last year) is also necessary prior to anesthesia. Undiagnosed heartworm positive canines could pose an anesthetic risk.
Microchip (including registration): $95.00
Express Anal Glands: $33.00
Nail Trim (no additional charge)

AUTHORIZATION

I have read and understand this authorization and consent and authorize the described surgical/anesthetic procedure and anesthesia for my pet.
I have not given my pet any food after 12 AM the morning of the procedure, unless otherwise advised by my veterinarian. I understand that this is important for anesthesia safety.

Name*

First Middle Last

Date*

Monday	8:00am – 6:00pm
Tuesday	8:00am – 6:00pm
Wednesday	8:00am – 6:00pm
Thursday	8:00am – 6:00pm
Friday	8:00am – 6:00pm
Saturday	8:00am – 12:30pm
Sunday	Closed

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Dentistry/Anesthesia Consent Form

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Dentistry/Anesthesia Consent Form

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