Procedure

Patient Name

Age

Owner Owner 12

Owner Name *

First

Last

Date *

Preferred Method of Contact

Mid-Day Phone Number

Use Multimedia?

Yes
No

Fasted for the past 12 hours?

Yes
No

Email *

Pre-Anesthetic Blood Testing and EKG *

I accept pre-anesthetic blood screening for my pet.
I decline pre-anesthetic blood screening for my pet, and I accept liability in connection therewith. (If your pet is 6 years of age or older this test is required.)
I accept EKG screening for my pet.
I decline EKG screening for my pet, and I accept liability in connection therewith. (If your pet is 6 years of age or older this test is required.)

Like you, our greatest concern is the well-being of your pet. Before putting your pet under anesthesia, we will perform a pre-surgical examination. However, many conditions, including disorders of the liver, kidneys, heart or blood, are not detected unless EKG and blood testing are performed. Such tests are especially important before any type of surgical procedure. For these reasons, we highly recommend heart ($52.50) and blood ($108.75) screening and will perform these tests unless declined. Our laboratory is fully equipped and staffed to perform these important heart and blood tests. Results will be immediately available to examine before anesthesia and/or surgery.

Additional Procedures

Please mark any additional procedures you would like performed while your pet is under anesthesia.

Dentistry Information *

I accept Full Mouth Dental X-rays canine ($226.50)
Second Choice decline Full Mouth Dental X-rays canine ($226.50)
I accept Full Mouth Dental X-rays feline ($143.50)
Decline Full Mouth Dental X-rays feline ($143.50)
I accept single view Dental X-ray of the suspected diseased tooth ($38.00/view not to exceed the price of Full Mouth)
I decline a single view Dental X-ray of the suspected diseased tooth ($38.00/view not to exceed the price of Full Mouth)

Applicable to all animals undergoing a dental procedure: Our pets require sedation before a thorough evaluation of the mouth can be completed. While your pet is under anesthesia an x-ray of the mouth will be obtained to identify the presence of disease. The teeth will be completely cleaned, polished, and examined. The doctor will then extract any teeth that are loose, decaying, or pose a future health risk for your pet. It is much safer and cost-effective to complete all dental procedures during this initial visit rather than schedule another appointment with general anesthesia required. Please understand that we will only do what we deem necessary for the future health and well-being of your pet.

Home Care

Dentacetic Wipes
CET
T/D
Toothbrush Kit

Owner Release

I understand that the veterinarians and staff will use all reasonable precautions against injury, escape, or death of my pet. I understand that all anesthesia involves some minimal risk to my pet, and I will not hold the veterinarian and/or staff responsible under any circumstances. I understand that I assume all risks.

Consent *

I have read all of the above information and agree.

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