Dental Consent Form

Client(Required)

First

Last

Patient(Required)

Sex

Male

Female

Approximate DOB or Age(Required)

Species

Canine

Feline

Other

Breed(Required)

My signature below confirms that I authorize Falconbridge Animal Hospital and/or Village Veterinary Hospital to perform a dental cleaning on my pet. I fully understand the nature and the scope of the procedure(s) being performed on my pet and the potential risk involved. I also understand that no guarantee has been made as to results or a cure. In the event that additional procedures are deemed necessary, an attempt will be made to contact me before proceeding but I authorize the veterinarians to proceed as necessary if I am unreachable.

A pre-anesthetic blood screen will be performed on all pets undergoing anesthesia or sedation. Because we will be using injectable and oral medications, it is important to know whether there are any detectable signs of organ dysfunction. The type of pre-anesthetic bloodwork is dependent on the age and health of the pet. The cost ranges from $64 to $152.00. (INITIAL HERE)(Required)

I understand that if a tooth is diseased, extractions may be necessary. Extractions, pain medication, and antibiotics vary in price based on the time required and degree of difficulty. (INITIAL HERE)(Required)

I understand that it is sometimes necessary to x-ray teeth to evaluate the viability of the root and jaw and that this will be done at the doctors discretion at a cost of $52 to $80. (INITIAL HERE)(Required)

I understand that current Wellness Exams, Distemper, and Rabies vaccines are required for all pets, as well as Parvo, Bordetella, Flu Vaccine (H3N2), and a Fecal Flotation for dogs before admission to the hospital. Pets not current on vaccines/testing will be updated as long as it is deemed safe and advisable by a veterinarian. I understand that I am responsible for associated costs.

I certify that to the best of my knowledge my pet is free of all external parasites upon signing this release. If parasites, such as fleas or ticks, are found, I understand that my animal will be treated on admission for an additional cost.

Other services desired at additional cost:

Nail trim (complimentary)

Anal Gland Expression ($25.00)

Microchip Identification ($48.00)

Other

My pet has fasted for 12 hours:(Required)

Yes

My pet is on heartworm prevention:(Required)

Yes

We believe that keeping your pet as comfortable and pain-free as possible after the procedure will speed healing and recovery. Many animals do not show obvious signs of pain after surgical procedures, so it is up to us to provide them with pain relief both during and after procedures, before they show signs of discomfort. We use injectable medications both pre- and post- operatively. For continued pain relief at home, we provide either liquid or tablets.

Routine dental procedures for canines are approximately $540-$740. Routine dental procedures for felines are approximately $500-$600. If extractions, pain medications, x-rays, or antibiotics are necessary additional costs will be incurred. I understand that all charges are my responsibility and that payment is expected at the time of discharge.

I am aware that my pet will not be supervised overnight.

Falconbridge & Village Vets can use my pet's photos on FalconbridgeAnimal.com and their social media pages. (Like us on Facebook & follow us on lnstagram!)(Required)

Yes

Signature of Owner or Agent(Required)

Phone number on day of surgery(Required)

Date Signed

MM slash DD slash YYYY

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