Dental Consent Form Date Date Format: MM slash DD slash YYYY PLEASE READ EVERYTHING VERY CAREFULLYPhone # 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.Would you like a complimentary nail trim while your pet is here?*YesNoThere is an additional fee of $95 for the blood work*YesNoALREADY DONE (Within a Month)Pre- Surgical ECGto evaluate hear rhythm at an additional $40*YesNoMicrochip for $51*YesNoDental 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 which the veterinarian feels necessary ($15-120/tooth). The exact number of extractions cannot be predicted until after the teeth have been cleaned and gums examined. I am ware that may mean many teeth may have to be extracted but that will assure the best possible health for my pet. Extractions usually increase the total time of the anesthesia & dental procedure. Painful extraction may warrant local dental block ($30 per block). There is an additional anesthesia charge of $64 per 15 minutes, if routine dental exceeds 45 minutes in Dogs and 30 minutes for Cats.*YesNoI 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.*YesNoPlease 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 $300, $400, $500, Other/No limit for any additional necessary dental treatment.$300$400$500Other/No LimitOtherI have restricted food from my pet for 12 hours.*YesNoI have not given my pet medication during the previous 24 hours, unless directed to do so.*YesNoIf so, please list medication*Is your pet on any long term medication, if so please list*YesNoIf 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.CommentsThis field is for validation purposes and should be left unchanged.