Client Name *

Appointment Date *

Client Address *

Address Line 1

City

State

Zip Code

Phone *

Email *

Email Reminders *

Yes
No

Patient Name *

Daytime Name/Phone Number *

Procedures to be performed today *

Medications *

Known adverse reactions to any medications *

For our surgery patients under 8 years old, pre-anesthetic blood work is not required but we recommend it to identify "at risk" patients. The risks of anesthesia increase with age, therefore, if your pet is 8 years or older, we do not recommend surgery without pre-anesthetic screening *

Yes, I want the blood work for an additional $131
No, I decline this blood work and am aware of the risks.

Did your pet eat today? *

Yes
No

Have you noticed any vomiting, diarrhea, and/or coughing during the past 7 days? *

Yes
No

Does your pet have a history of allergic reactions or difficulty following anesthesia? *

Yes
No

Is your pet on any additional medication? *

Yes
No

What time did your pet receive medication today? *

Is your pet treated for fleas? (type and last date given) *

If your pet is not microchipped, would you like us to implant one today for $54? *

Yes
No

If the doctor feels it is necessary due to your pet's age/health condition, your pet may be put on IV/SQ fluids.

If your pet is not current on recommended and required vaccinations, I understand vaccinations will be administered today at the doctor's discretion. *

Clear Signature

(initial)

Are there any questions or concerns you have for the veterinarian?

NOTE: We are committed to the practice of high-quality medicine; therefore, your pet may be prescribed and you may be charged for additional pain relief medications and/or antibiotics upon discharge. In addition, Xray imaging is performed on all dental patients for a fee of $74.

Statement of Medical and Financial Responsibility:

I hereby give my consent and accept financial responsibility for the above listed procedure(s) to be performed. Even though pets are given a pre-procedure exam, I understand that there are risks involved in the administration of general anesthesia and in performing all surgeries; therefore, I give permission for the performance of any additional treatments necessary for the welfare of my pet.

I understand that payment is due in full upon my pet’s discharge. My method of payment will be: *

Check
Debit/Credit Card
Cash
Care Credit Account

Signature (copy) *

Clear Signature

Date *

Dentistry Admission and Consent Form

Contact

Location

Open Hours