Dental Consent Form

Dental Consent

Owner *

Client # *

Phone *

Alternate Phone *

Pet *

As the owner/agent of the animal listed, I hereby give consent to Triangle Animal Clinic to perform the following procedure(s) or operation(s): *

Preferred Provider *

I understand that during the performance of the above procedure(s), unforeseen conditions may be revealed that necessitate an extension or variance in the procedure(s) set forth above. I expect Triangle Animal Clinic to use reasonable care and judgment in performing the procedure(s). It is understood that anesthesia, surgery, medical treatment, restrain, hospitalization and sedation involves a small degree of risk of death or injury to my pet which the hospital staff has no control over and cannot be held responsible. The nature of the procedure and risks involved have been explained to me and I realize results cannot be guaranteed. I am also aware that unforeseen events resulting from the procedure(s) will not relieve me from my financial obligation to all reasonable costs incurred regarding this animal. *

Agree

All animals admitted must be: CURRENT ON ALL VACCINATIONS and MUST BE FREE OF EXTERNAL PARASITES. ANY ANIMAL FOUND TO HAVE FLEAS OR TICKS WILL BE TREATED AT THE OWNER’S EXPENSE. Treatments include (but are not limited to): *Capstar *Revolution *Bravecto *

Agree

Pre-anesthetic blood screen: Due to pre-existing conditions not evident during routine examinations. To avoid these problems, we recommend that all surgical patients be screened prior to anesthesia by means of laboratory tests. Can detect anemia, early kidney damage or liver disease, diabetes or dehydration. Triangle Animal Clinic recommends pre-anesthetic screening on all surgical patients. Animals at great risk are those 5 – 7 years of age who may have early signs of disease; geriatric animals greater than 8 years old are at high risk of complications associated with anesthesia. $88.00 *

Yes

No

Doxirobe Gel: Is used for treatment and control of periodontal disease. It is applied beneath the gum line to pocket(s) around affected teeth, providing a local antimicrobial effect. It can help reduce periodontal pocket depth, increase gum reattachment and reduce gingival inflammation. This is on an as needed basis and only used if necessary. $68.27 *

Yes

No

Extractions: While cleaning the teeth, we are often able to provide treatments that would be an alternative to performing extraction(s) of a dog or cat’s teeth. However, it may be necessary to extract teeth due to tooth related infection, pain or other oral diseases that cannot be controlled by other means. *

Yes

No

Extractions are not included in the price of dental cleaning and will be charged based on severity and type of tooth removal. I request a call if the cost of extractions will be in excess of

If you request a call prior to extractions, you MUST be reachable via phone within 3 minutes of the initial call. If we are unable to reach you, extractions will not be performed. This time line is strict because your pet is under anesthesia and minimal anesthesia time for each patient is our protocol. If we are unable to reach you, another anesthetic procedure will need to be scheduled for a later date upon discharge. Phone:

Dental radiographs: X-rays are available for further evaluation of the teeth and the roots of the teeth that cannot be visualized with the naked eye. Oftentimes, teeth may look normal on the surface but the tooth roots will indicate that oral surgery/extractions are critical to your pet’s health, safety, and to alleviate pain. $94.00 *

Yes

No

Microchip: If your pet does not already have a microchip, would you like this performed at this time? $44.38 *

Yes

No

Signature