Dental Admission Form Dental Admission Form Owner's Name * Owner's Name First First Last Last Pet's Name * Home Phone * Email * Are vaccinations current? * - Please Select -YesNo If so, where? If not, please update today. Any vomiting, coughing, sneezing, diarrhea? * - Please Select -YesNo Did your pet eat this morning? * - Please Select -YesNo Is your pet allergic to any drugs? * - Please Select -YesNo Has your pet had any accidents or illness in the last 30 days? * - Please Select -YesNo If yes, what? * If yes, please describe * Is your pet currently on any medication? * - Please Select -YesNo Any other specific problems to be checked? * - Please Select -YesNo If yes, what? * If yes, what? * Any dental hygiene products used on a regular basis? * - Please Select -YesNo Does your pet have a history of seizures? * - Please Select -YesNo If yes, what? * Take home pain medication and antibiotics will be added at an additional fee if extractions are performed. * I agree Elective Procedures to be Done at the Same Time These are simple procedures that do not greatly increase sedation/anesthesia time and therefore can be provided at a fee less than would be required otherwise (when sedation would be required for the separate procedure) when done at the same time as the dental prophy: Please check * Ear canal irrigation ($130.38) Express anal sacs Dewclaw removal Ear cleaning Brush out / clip hair mats Microchip Remove warts / skin growth Other procedures you would like performed at this timeOther procedures you would like performed at this time Location of warts / skin growth * Extraction & Other Procedures Consent / Waiver Many pets require sedation before a thorough examination can be completed. The condition of each tooth must be evaluated before a decision is made as to the best course of treatment. Although no one likes surprises, it sometimes is impossible to give an accurate estimate before sedation. From an economic standpoint, it is much more economical to complete all needed dental procedures during the initial visit and sedation rather than having to schedule another appointment with additional sedation required. In an effort to satisfy your desires, please select the appropriate option below * Please perform whatever procedures & extractions are required at this time. Please call me after the exam with an estimate if any additional procedures are needed. Do not proceed without authorization. Phone number where I can be reached today: * Please note that if you cannot be reached, the veterinarian will proceed with needed dental procedures. * I agree Pre-Anesthetic Screening Consent / Waiver Like you, our greatest concern is the well-being of your pet. A physical examination will be performed before sedating your pet. However, many conditions, including disorders of the kidneys, liver, heart & blood cannot be detected without blood lab screening and heart electrocardiograms. For these reasons, we highly recommend pre-operative screening before sedating your pet. Please choose one * YES - I want to ensure my pet's safety. Perform a complete blood screen for $103.71 (Recommended for 1st time anesthesia, geriatric, or debilitated pets) YES - I want to ensure my pet's safety. Perform a mini blood screen for $67.68 (Recommended for all other pets undergoing surgery) NO - I assume total responsibility for my actions, by refusing to approve this blood testing for my pet's safety Owner Release: You are to use all reasonable precaution against injury, escape, or death of my pet. I understand that all sedation/anesthesia involves some minimal risk to my pet, but you will not be held liable in any manner whatsoever or under any circumstances in connection therewith as it is thoroughly understood that I assume all risks. I have read the foregoing and agree. Signature signature keyboard Clear Date Captcha Submit If you are human, leave this field blank.
