Dental Consent Form Are you a new client?(Required) Yes No Please complete our New Client Form before your visit.Owner's Name(Required) First Last Best phone number to contact after procedure(Required)Email(Required) Today's Date(Required) MM slash DD slash YYYY Date of Procedure(Required) MM slash DD slash YYYY Pet's Name(Required) Is this a new pet?(Required) Yes No HiddenPet infoSpecies(Required) Dog Cat Breed(Required) Color(Required) Age/Date of Birth(Required) Sex(Required) Male Male (neutered) Female Female (spayed) Is your pet microchipped?(Required) Yes No Name of Previous Clinic Previous Clinic PhoneMay we request medical records? Yes No Any previous illnesses or surgeries?(Required) Yes No If yes, please explain(Required)Is your pet on any special diets or medications?(Required) Yes No If yes, please list the medication name and dosage and/or special diets(Required)Did they receive medication this morning?(Required) Yes No What medication?(Required) HiddenSection BreakLike you, our greatest concern is the well-being of your pet. Prior to administering anesthesia to your pet, a full physical exam is performed. Included in the price of each surgery/procedure is: An intravenous catheter and fluid therapy Pain medication before the procedure and medication to go home Anesthesia monitoring Blue Diamond Animal Hospital staff Veterinary Graduates Awaiting Licensure (VGAL). While they possess the necessary skills and knowledge, it is essential to acknowledge that their licensure is pending. The well being of the animal remains the primary concern. I'm aware of this arrangement and provide consent to proceed.(Required) I have read and understand this authorization and consent. I further understand that I assume financial responsibility for all services rendered Your pet will be undergoing general anesthesia plus a surgical procedure today. In order to recognize any underlying abnormalities your pet may have, we highly recommend having a pre-surgical blood profile run on your animal. This consists of a CBC, which will check blood cells and chemistry which will also check blood glucose, kidney, and liver enzymes. These blood tests will help us to assess the health status of your pet more completely and determine if there are any additional precautions we need to take before surgery. We require a blood profile for animals older than seven years.(Required) I have read and understand Cardiac Circulatory Pulmonary Resuscitation: I understand that risks and potential complications exist with anesthesia surgery and do not hold Blue Diamond Animal Hospital liable for those risks. The Attending veterinarian will perform any necessary emergency care and I agree to assume all financial responsibility associated with my decision. I authorize the attending veterinarian to perform CPR I do not authorize the attending veterinarian to perform CPR Is your pet current on their vaccines?(Required) Yes No My pet(s) need vaccines and I will cover the cost for the vaccines (Required for admission)Please select the vaccines your dog needs:(Required) DHA2P Parvo Bordetella Rabies Fecal Corona Biv Influenza Please select the vaccines your cat needs:(Required) FVRCP FeLV Fecal Rabies Has your pet ever had any vaccine reactions (vomiting, diarrhea, facial swelling, hives, etc.)?(Required) Yes No If yes, please explain(Required)Has your pet ever had a seizure?(Required) Yes No If yes, please explain(Required) Any coughing, vomiting, diarrhea?(Required) Yes No If yes, please explain(Required) Any illnesses in the past 30 days?(Required) Yes No If yes, please explain(Required) If yes, did they receive medication this morning?(Required) Yes No Recommended/Optional Services (Additional Cost)Pre-surgical blood testing is recommended to help reduce the risks involved with anesthesia. This test checks the internal status of your pet, including liver and kidney function (these are the main organs that metabolize anesthesia, complete blood count, and blood glucose level. Please select the option below if you'd like to add pre-surgical blood testing.(Required) Pre-anesthetic panel with CBC (recommended for pets under 7 years) ($125) Comprehensive chemistry panel with CBC (required for pets over 7 years) ($175) Decline Recommended for all pets 7 years or older. - Required for those pets with a heart murmur prior to any anesthetic procedure. An ECG evaluates the heart's rhythm, and may aid in the diagnosis of a potential issue with the heart.(Required) Accept ($86) Decline Many patients experience vomiting following the administration of some anesthetic drugs. Cerenia can help prevent vomiting on the day of surgery, as well as help them return to normal feeding sooner.(Required) Accept ($64) Decline Recommended to aid in pain relief and healing after dental extractions. An opioid injection will be administered after the surgical procedure is done, and an additional oral pain medication will be sent home with you. (Pet's who do not require dental extractions will not be given additional pain medication).(Required) Accept ($60-$90) Decline If your pet's doctor deems extractions are necessary, we will attempt to reach you at the number you have provided and give you an estimate for the additional cost. If we are unable to reach you at the phone number you provided, and your pet's doctor deems extractions are necessary, please select one of the following:(Required) APPROVE: I approve all necessary dental procedures needed at this time. I accept full responsibility of financial charges associated with this decision. CALL BEFORE: I would like to be called before any extractions are done. If I cannot be reached, I do not authorize the staff at Blue Diamond Animal Hospital to proceed. A detailed treatment plan will be provided to me at the time of discharge. DO NOT CALL: I would not like to be called for any additional procedures, other than an emergency situation. Do not perform any additional dental work. A treatment plan will be provided to me at the time of discharge. Full mouth dental radiographs are highly recommended for routine dental cleanings. This allows the veterinarian to see below the gum line and evaluate tooth root health. If your pet has poor dental health and needs dental extractions, the radiographs will be MANDATORY.(Required) I have read and authorize ($110) I have read and decline full mouth dental radiographs at this time. Laser Therapy promotes faster healing of any incision site. Laser Therapy is for patients with extractions ONLY. We highly recommend post-surgery laser therapy as it helps reduce healing time as well as time spent in an E-collar. If Cancer is suspected, laser therapy is not advisable.(Required) Accept ($24) Decline Deep Ear Cleaning: It can be hard to clear debris in our pet’s ears when they are awake. We offer this service to do an in-depth cleaning while they are under anesthesia.(Required) Accept ($48) Decline Nail Trim (Complimentary during dental season)(Required) Accept ($16) Decline Nail Dremel(Required)(a high powered rotary tool is used to file down the nails, leaving a smooth and rounded appearance) Accept ($33) Decline Anal Gland Expression(Required) Accept ($20) Decline Microchip Implantation (Includes registration)(Required) Accept ($50) Decline As the owner or agent of the above animal, 18 years of age or older, I hereby give my consent to Blue Diamond Animal Hospital to perform a dental cleaning on my pet.(Required) I agree I, the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above and have the authority to execute this consent. I understand that during the performance of the procedure, an unforeseen situation may arise that necessitates an extension or variance in the procedure set above. I hereby authorize Blue Diamond Animal Hospital to use reasonable care and judgment in performing the procedure. I have been advised as to the nature of the procedures and the risks involved in performing general anesthesia on the above-described animal. I realize that results cannot be guaranteed. I understand that all pets presented to Blue Diamond Animal Hospital for a procedure must be current on vaccinations.(Required) I have read and understand this authorization and consent. I further understand that I assume financial responsibility for all services rendered Digital Signature(Required) Date(Required) MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.
