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Dental Admission Form
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Email
This field is for validation purposes and should be left unchanged.
Please provide at least 24 hours prior to appointment
Dogs/Cats: Please withhold food and water 12 hours before your pet's admission appointment.
For Exotics/Birds please call the hospital for withholding food and water instructions.
Name
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First
Last
Address
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Street Address
City
State / Province / Region
ZIP / Postal Code
Email Address
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Phone
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Pet's Name
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Pet's Procedure
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Have you been exposed to anyone knowingly with COVID-19 illness in the last 14 days?
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Yes
No
Are you or any family member experiencing any signs of COVID-19 illness like fever, cough, body-aches, or loss of taste or smell?
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Yes
No
Note: Masks are now optional to wear on the day of your appointment.
I, the undersigned owner, or owner's authorized agent of the above pet certify that
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I am over eighteen years of age
I am not over eighteen years of age
Is your pet on medication?
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Yes
No
I have been informed that my pet is in need of preventive or therapeutic dental care and hereby consent to the appropriate procedures described to me by the veterinarian and her staff at this facility. These procedures include but are not limited to the following: 1) dental prophylaxis (routine teeth cleaning and polishing), 2) extractions, 3) oral surgery to close gaps left by extractions, 4) root planings, 5) dental x-rays, and 6) antibiotic gel implants.
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I consent
I am aware that dental procedures for animals require the use of anesthesia to: 1) maximize visualization of the gums, teeth, and oral cavity, 2) minimize movement and discomfort, and 3) provide for the safety of the pet, doctor, and hospital staff. I understand that some risks always exist with anesthesia and dental procedures and that I am encouraged to discuss any concerns I have about those risks with the veterinarian before these procedures are initiated.
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I am aware and understand.
Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff:
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does have (CPR) my permission to provide such treatment and I agree to pay for such services.
does not have (DNR) my permission to provide such treatment and I agree to pay for such services.
I have been informed that examinations under anesthesia often reveal dental disease and abnormally loose teeth that fall out or should be extracted to prevent oral discomfort and ongoing infection of surrounding bone. I also have been informed that the loss or removal of one or more unhealthy canine teeth occasionally allows for an awkward protrusion of the tongue to one side or the other.
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I have been informed
Please choose one of the following
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If I cannot be reached while my pet is undergoing anesthesia and dental care, I consent to additional extractions or procedures at the discretion of the veterinarian and agree to pay for all related fees. Otherwise, all questions and concerns I have about the recommended dental procedures have been answered to my satisfaction.
If I cannot be reached while my pet is undergoing anesthesia and dental care, I do not consent to additional extractions or procedures that would be recommended by the veterinarian while my pet is under anesthesia.
I understand that a treatment plan of the fees for the above procedures will be emailed to me and that I am encouraged to discuss all fees related to such care before services are rendered. I agree to pay and assume financial responsibility for the balance of services rendered, and agree to provide payment of cash or credit card on the day of service. I understand full payment is required at the time of service
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I agree
Date
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Signature
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First
Last
I will take my pet’s belongings home with me (leashes, sweater, toy etc.):
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Yes
No
We prefer that you take your pet’s belongings (collar, leash, etc..) home with you.
If you need to leave any belongings here, please list below (include color of items):
If you are leaving your pet’s crate at the hospital, please list color and label your carrier with your pet's name.
If it is recommended for your pet to go home with oral medications would you prefer (sometimes liquid is not available for some medications)
liquid medications
pill/capsule medications
Please list any medications your pet is currently taking and if you need a refill of medications
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In addition to this estimate I would like the following procedures to be performed on my pet, while he/she is under anesthesia and or sedation today and I agree to be responsible for the additional cost of these items as listed below
$0 Nail trim
$60 Nail trim and Dremel (smooths sharp edges)
$67.50 Anal sac expression
$98.50 Microchipping
$57.00 Ear cleaning
$172.00 Pelvic radiograph (hip evaluation)
$0 Permission to board multiple pets from same family in one kennel
$100 Dr. discretion – Miscellaneous (if you cannot be reached by phone)
Doctor discretion – treatment items recommended if you cannot be reached by phone. Please leave dollar amount you authorize:
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