Hurricane Animal Hospital Consent Before Dentistry Procedure

We have ________________ (pet’s name)_ scheduled for a dental cleaning on _____________________(date)____. Please arrive at the hospital at _______am for your admission appointment.

Blood Testing

Like you, our greatest concern is your pet’s safety and wellbeing during anesthesia. If acceptable lab tests have NOT been completed, we strongly recommend these before your pet has anesthesia. Please initial one of the lines to accept a desired profile OR to decline. IF testing was ran in advance of the procedure leave this section blank until admission appointment.

Profile #1 – recommended for all pets 2 years old and under in good health. $116.62 (Chem 8 + and ECG)

Profile #2 – recommended for pets age 2-7 years or with questionable health. $144.65 (Comprehensive Dx Profile, CBC, and ECG)

Profile #3 – recommended for all pets over 7 or with illness/conditions requiring thyroid check. $245.60 (Comprehensive Dx profile, CBC, T4/Chol, Urinalysis strip with specific gravity, and ECG)

I have read the brochure explaining pre-anesthesia blood testing and have had the opportunity to ask questions to the staff members and/or doctors at Hurricane Animal Hospital. I have chosen to decline the recommended pre-anesthesia bloodwork at this time and request to proceed with anesthesia.

I elect to DECLINE blood testing.

Decline

Surgical Extractions

Our goal is to keep every tooth functional and pain-free. Sometimes a tooth needs to be surgically removed to return the mouth back to a functional & pain free part of the body. We may find teeth that are loose, infected, or damaged & should be extracted. We do not remove any teeth unless it is medically necessary to do so. Infected or broken/damaged teeth can lead to dental abscesses, pain when eating, and can lead to infections elsewhere in the body as the bacteria enter the bloodstream and travel to the heart, kidneys and liver. It is important to extract these problem teeth to keep your pet healthy and prevent problems in the future.

Dental procedures, including simple and surgical extractions can be associated with risks. I understand these risks may include broken tooth roots, bleeding, dry sockets, and damage to surrounding tissues. Rarely, fractures of the jaw bone may occur, necessitating further work. At our hospital, every effort is made to predict and avoid these complications, but unforeseen events can occur. I understand these risks.

Initials *

Please check the appropriate box(es) below:

Please do any and all procedures you deem necessary to treat current problems, minimize any pain my pet might experience in the future from ongoing dental disease, or any other abnormalities discovered in the mouth and throat. I am aware that this may involve the extraction/removal of one or several teeth, oral surgery, or other medical treatments as indicated.
I am aware that in the event that I check any of the following boxes, and I cannot be contacted by the hospital team, my pet may require an additional anesthetic procedure, at an additional cost, to pursue any additional problems at another time:

Please do any and all procedures you deem necessary, but do not exceed_______ (dollar amount) without contacting me.

Please do NOT, under any circumstances, proceed with anything more than routine cleaning without contacting me.

Please do NOT extract any "marginal" teeth, which might require extraction in the near future. I am aware that this will require significant follow up care to prevent rapid progression of disease and possibly increased pain until the next dental procedures are performed.

I would be interested in pursuing specialized care, even if this means leaving currently-diseased and potentially painful teeth in the mouth until I can make an appointment for my pet with a veterinary dental specialist (at the University or Specialty hospital).

Dental Radiographs

Dental x-rays allow us to look beyond the obvious and better exam teeth and the supporting structures below the gumline. X-rays many times reveal hidden and undiagnosed conditions. For that reason, dental radiology is recommended for all dental cleanings but is especially important for any dental cleaning where we anticipate extractions, or where grade 3-4 gingivitis exists. We also recommend x-rays after the extraction of teeth to ensure that all tooth root fragments have been successfully removed and that the surrounding bone is healthy. This greatly minimizes post-surgical complications.

Cost of x-rays: $120 for dogs, $75 for cats

I agree to have dental x-rays performed on my pet today Initials *

I decline dental x-rays performed on my pet today, and understand the associated risks Initials *

Other Services to do while my pet is sedated:

Please trim my pet’s nails ($13.31)

Please clean my pet’s ears ($13.55)

Please express my pet’s anal glands ($15.75)

Please microchip my pet ($55.72)

Please provide the following vaccines for my pet today:

Dog:

Rabies ($16.35) DHLPPC (21.36) Bordetella ($16.61) Lyme($25.06) Canine Influenza ($35.00)

Cat:

Rabies($16.35) FVRCP($21.36) Feline Leukemia($21.22)

Other services needed:

Pain Control

All pets will receive an injection for pain control in the hospital and medication to provide relief after surgical extractions (for 3-5 days).

I am the owner/agent for the described animal and I authorize and request the services listed on this form and /or outlined on the estimate provided for my pet’s care. I understand, and accept that when anesthesia is involved, there are always inherent risks, including death. I have indicated any additional services I would like performed. I understand that pain medication will be provided to keep my pet comfortable after the procedure. I can be reached at ________________________ if needed for questions during the surgery. Further, I understand that if I am unreachable at the time, Hurricane Animal Hospital will determine what is medically in the best interest of my pet. I understand that I will be financially responsible for these services.

Owner’s Signature

Clear

Date

Date Date Picker Icon