Dental Consent Form in Petersburg, FL - Grand Central Veterinary Hospital

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Client Name*

First Last

Primary Phone*

Secondary Phone

Pet's Name*

Email Address*

Procedures Elected*

Dental Cleaning

Growth Removal

Please select from the following options for further diagnostics on the growths to be removed.*

Histopathology

In-clinic cytology

Decline further diagnostics

Additional Surgical Procedures*

Yes

Additional Surgical Procedure:*

Procedural Information and Hospital Policy

Pre-anesthetic Blood Testing: Pre-surgical blood tests along with physical exams are required prior to all dental procedures as they will enable us to assess and minimize the risk of anesthesia to your pet by creating a protocol tapered to your pet’s specific needs.

Blood Work Completed?*

Yes

Date of Completion*

MM slash DD slash YYYY

Pre-Anesthetic Testing

Heartworm with Tick Disease Screen (Dogs only)

Heartworm with Feline Leukemia and FIV Screen (Cats only)

Complete Blood Cell Count

Blood Chemistry Panel

Decline all diagnostic testing

Monitoring:To minimize anesthetic risk, we monitor your pet’s heart rate, blood pressure, respiratory rate, temperature, and oxygenation throughout the procedure.

Catheterization:For sterility, hair will be shaved over a vein on the leg so that an intravenous (IV) catheter can be placed. Blood pressure may lower during anesthetic procedures and fluid therapy aids in supporting your pet’s internal organ systems. It, also, allows immediate access to the vascular system in case of an emergency.

Pain Management:The doctors will administer pain medications according to your pet’s needs before, during, and after the procedure. Some pain medications can incur an additional fee.

Antibiotics:The doctors may administer antibiotics according to your pet’s needs. These medications may incur an additional fee.

General Patient History and Information

Did your pet eat this morning?*

Yes

How Much Did They Eat?

When did they eat?*

Species (choose dog or cat)?*

Dog

Cat

Rabies?*

Yes

DHPP?*

Yes

Bordetella?*

Yes

CVRP (Upper Respiratory combo)?*

Yes

Leukemia?*

Yes

Please note if your pet is not current on their Rabies vaccination, they will receive a vaccine today.

Has your pet experienced any vomiting or diarrhea within the past two weeks?*

Yes

Vomiting, Diarrhea, or Both?*

Vomiting

Diarrhea

Both

When did you notice it?*

Has it Resolved?*

Yes

Has your pet experienced any coughing or sneezing within the past two weeks?*

Yes

Coughing, Sneezing, or Both?*

Coughing

Sneezing

Both

When did you notice it?*

Has it Resolved?*

Yes

Does your pet have a history of seizures?*

Yes

When was the last seizure?*

Is your pet currently on anti-seizure medications?*

Yes

What Type?*

When was their last dose?*

Does your pet have a history of allergies to any drugs or medications?*

Yes

Does your pet have a history of any illnesses or injuries we need to be aware of today?*

Yes

Is your pet currently taking any medications? Including any preventatives or supplements.*

Yes

Please Explain:*

Does your pet have a history of allergies to any drugs or medications?

Please Explain:*

Does your pet have a history of any illnesses or injuries we need to be aware of today?

Please list medications or supplements and when their last dose was given.*

Is your pet currently taking any medications? Including any preventatives or supplements.

Please note if any fleas or ticks are found on your pet while in the hospital, they will be treated at an additional cost to you.

Dental Extractions

It can be difficult to predict if teeth need to be extracted when an animal is awake because tartar and movement interfere with assessment. Severe dental disease and damaged teeth can cause considerable pain and discomfort to your pet. They are, also, a potential source of infection for other organ systems (liver, kidney, lungs, and heart). During the dental cleaning, the teeth will be evaluated by the attending veterinarian to determine if extraction is necessary.

Please choose one of the following options*

I authorize all medically necessary extractions to be performed.

I authorize all medically necessary extractions within a numerical constraint.

I prefer to be called prior to any extractions being performed.

Numerical Constraint:*

I understand if I cannot be reached in a timely manner, no extractions will be made and an additional procedure with anesthesia may be required in the near future, resulting in additional cost to me.*

I Understand

Optional Procedures

Nail trim

Anal gland

Ear Cleaning

Ear Hair

Microchip

CPR

I am mindful that during the operation/procedure, unforeseen conditions may arise that may require the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before the procedure is initiated.*

I have read and agree.

In the event your pet should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of your pet’s status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitative efforts will continue to be performed at the doctor’s discretion.*

I agree to CPR being performed in case of arrest.

I elect a “Do Not Resuscitate” status in case of arrest.

For the safety of your pet and others, we ask that all animals coming into the building be restrained by a leash or in a carrier upon arrival. Those individuals without proper restraint may request assistance upon arrival.

The client has received a written estimate and has had the opportunity to review the estimate and ask any questions or express concerns, and that their questions have been answered to their satisfaction, and they agree to the amount of the estimate given.

We try our best to provide the most accurate estimate, occasionally unforeseen circumstances may arise that may result in additional fees

Acknowledgements

I am the owner or authorized agent for the pet described above and have the authority to execute this consent. By signing this document, I certify that I am over eighteen years of age. I agree to make myself available by phone between the hours of 8:30am – 6:00pm.

I hereby agree that I have been informed of and understand there are certain risks and possible complications associated with dental procedures and the anesthesia or sedation associated with those procedures, and after being informed of the nature of the dental procedure and those services elected by me, I understand what will be done for my pet.

I am mindful that while Grand Central Veterinary Hospital provides the highest quality of anesthesia, surgical and dental services, it is possible that during the operation/procedure, unforeseen conditions may arise that may require the performance of additional procedures deemed necessary by the veterinarian. I fully acknowledge and understand these risks, knowing that the hospital and the hospital staff will do all that is necessary to minimize these risks. Additionally, I authorize Grand Central Veterinary Hospital to perform any diagnostic, medical treatment, surgical procedure, or dentistry as deemed necessary for any unforeseen medical or surgical complications if one should arise. I will hold harmless and without blame Grand Central Veterinary Hospital, the veterinarian, or any hospital staff members for any complications that should arise during my pet’s medical treatment and care. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian prior to the procedure taking place.

I authorize the use of appropriate anesthesia and pain relief medications as needed before, during, or after the procedure. I have been informed that there are risks associated with the use of any medications.

I understand the practice of veterinary medicine is not an exact science and thus, there are no warranty or guarantees that can be awarded to me as to the results or cure afforded by the treatments or procedures performed today. I have been awarded the opportunity to discuss any questions I may have regarding the care of my pet to my satisfaction, and it is my responsibility to do so. I accept that my financial obligation remains regardless of any outcome.

I will not hold liable Grand Central Veterinary Hospital, the veterinarian, or any hospital staff members for the loss or damage of any personal items (leashes, collars, blankets, etc.) that is left at the hospital. If I neglect to pick up my pet or any personal items within a 5-days from the date below, Grand Central Veterinary Hospital will assume abandonment of my pet or personal items.

By signing this consent form, I agree to leave a deposit in the amount equal to 50% of the estimate for services and pay the full balance due for services rendered by the end of the business day that I pick up my pet, including those deemed necessary by the veterinarian for any medical complications or unforeseen circumstances. Furthermore, I understand regardless of the outcome of treatment, I am responsible for payment of the procedures performed today. If for any reason there are financial restrictions associated with this visit, it is my responsibility as the owner to notify a staff member immediately of such limitations.

** Dental / surgical pick-up times are between 3:00 PM-6:00 PM **

I have read and understood this authorization and acknowledgements, and I hereby accept and consent to its terms and to the treatment of my pet.*

Initials

Signature*

Date*

MM slash DD slash YYYY

This field is for validation purposes and should be left unchanged.

Dental Consent Form

Procedural Information and Hospital Policy

General Patient History and Information

Dental Extractions

CPR

Acknowledgements

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