Dental Consent Form in San Jose, CA | Lincoln Avenue Veterinary Clinic

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Date

PLEASE READ EVERYTHING VERY CAREFULLY

Phone # where you can be reached today:*

Pet's Name*

Any Additional Procedure Requested:

As with any anesthetic or surgical procedure, there are risks that cannot be predicted or eliminated. For the protection of your pet, we strongly recommend doing a pre-anesthetic blood profile. This will ensure that your pet is a lower-risk candidate during the anesthesia by ruling out many pre-existing internal problems; these conditions may be evident physically but could possibly lead to complications. We will place an intravenous catheter and administer pain control medications to your pet as deemed fit, according to your pet's specific needs.

Product Name

Species (Dental Base Price)*

Dogs - $675.00
Cats - $585.00

Would you like a complimentary nail trim while your pet is here?*

Yes
No

There is an additional fee of $150.00 for the blood work*

Yes
No
ALREADY DONE (Within a Month)

Pre- Surgical ECG to evaluate heart rhythm at an additional $40*

Yes
No

Microchip for $52*

Yes
No

Dental disease can be so extensive that it may require extractions. Extractions range from $16-120/tooth. Extraction is the last resort for a very diseased tooth. This addresses the tooth disease & prevents this source of infection from spreading elsewhere in the body.

Please check the appropriate response below:

I approve of ANY extractions the veterinarian feels are necessary ($15–$120 per tooth). The exact number of extractions cannot be determined until after the teeth have been cleaned and the gums examined. I understand that this may mean multiple teeth could need to be extracted, but this will help ensure the best possible health for my pet. Extractions may increase the total time of the anesthesia and dental procedure. Painful extractions may require a local dental block ($30 per block). For the protection of my pet, I understand and accept the recommendation for a pre-anesthetic blood profile ($75), which helps confirm my pet is a lower-risk candidate for anesthesia by identifying potential underlying health issues. There is an additional anesthesia charge of $75 per 15 minutes if the routine dental procedure exceeds 60 minutes for dogs or 45 minutes for cats.*

Yes
No

I approve of gingivectomy if the veterinarian feels removal of a portion of loose gums will help in saving the inflamed tooth/teeth. Additional cost of $71.50/10 minutes of surgical time.*

Yes
No

Please DO NOT write "call first," as the decision to extract teeth or do a gingivectomy cannot be made until your pet is under anesthesia and the cleaning has already been done. We do not want to keep your pet under anesthesia any longer then absolutely necessary. Of course we will only do a procedure if it is medically necessary and in the best interest of the patient.

Use best judgment but only spend up to an additional amount of $400, $600, $800, Other/No limit for any additional necessary dental treatment.

$400
$600
$800
Other/No Limit

Other

I have restricted food from my pet for 12 hours.*

Yes
No

I have not given my pet medication during the previous 24 hours, unless directed to do so.*

Yes
No

If so, please list medication*

Is your pet on any long term medication, if so please list*

Yes
No

If so, please list medication*

*Pick-up Policy: All pets must be picked up before 6PM. If you arrive before 6:15PM you will be charged a late fee of $15, if you arrive after 6:15PM, your pet will be boarded overnight and a boarding fee will be applied.

I understand the above and give my consent for my animal.