Companion Animal Hospital Dental Sx Form

PET’S NAME:

OWNER’S NAME

First Name Last Name

Date

Date Date Picker Icon

DENTAL/SURGICAL/PROCEDURE:

Fasting for Surgery

When did pet last eat?

What meds is your pet taking?

Last given?

DOG OWNERS

Current on vaccines? (Rabies, Distemper, bordetella)

Yes No

Heartworm test within last year?

Yes No

Need heartworm test today?

Yes No

Need fecal today?

Yes No

Need heartworm/flea prevention?

Yes No

Need Influenza vax?

Yes No

CAT OWNERS

Previously tested for FELV/FIV?

Yes No

Need FELV/FIV test today?

Yes No

Current on vaccines? (Rabies, Distemper)

Yes No

Need Leukemia vax?

Yes No

Pre-Anesthetic Blood Screening
***(Required for pets 5 yr and older)***
Blood screens alert doctors to any potential health
problems while ensuring that your pet is healthy
enough for anesthesia/surgery.

I want a blood screen on my pet.

Yes No

Choose one:

Chem 10/cbc (5-7yr) $110 Chem 17/cbc (8yr & older) $117

Consent for Extraction

Please do whatever is needed Please do whatever is needed up to amount authorized Please call me first for any additional treatment. Please do nothing more than I have authorized.

Initials *

Microchip

One time permanent ID $40.

I would like a microchip.

Yes No

Authorization to Proceed.

I authorize the use of appropriate anesthesia/medications and support the personnel judgment of the Veterinarian. I understand even though every precaution is taken, anytime an animal is anesthetized there is a slight risk that an adverse reaction could potentially occur resulting in death.

2. I understand that during the above listed procedures an unforeseen medical condition may become evident that necessitates an extension of or an addition to these procedures. I authorize the performance of such procedures as are perceived necessary in the professional judgment of the Veterinarian.

3. I understand that the result of any procedures/operation cannot be guaranteed.

Initials *

I am aware of the risks and understand the information presented in this consent form, and I give the authorization to proceed with procedures/surgery and perform any and all life-saving procedures should the need arise.

Signature

Clear

Phone Number

Area Code Phone Number