Chimney Rock Animal Hospital

Dentistry Consent Form

Save time during your next appointment! Complete your required dentistry consent form from any device at any time before your visit.

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Online Form

Dentistry Consent Form

Client's Name *

First

Last

Email *

Emergency Phone Number *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Patient's Name *

Species *

Breed *

Sex *

Color *

Weight *

Anesthetic and surgical procedure(s) to be performed:

Complete Oral Health Assesment under general anesthesia
Scaling and polishing of all eligible teeth
Simple extractions * Additional charge will apply *
Surgical extractions of multi-rooted teeth ** Only performed on patients that have had an Oral HealthAssessment in last 6 months or with prior arrangement. Additional surgical/medical charges will apply**

Additional Surgical Procedures: {Additionals}

Microchip: approved

Pre-Surgical Bloodwork: *

Yes
No
Already ran

We offer and recommend pre-anesthetic blood testing to check for underlying or congenital conditions that may compromise the patient under anesthesia. This testing is required for patients over 6 (six) years of age or at the discretion of the doctor. The cost for this testing is addition to the above procedure(s) is $89.

Plaque Prevention Gel: *

To help prevent gingivitis and tooth loss, we can apply a sealant to your pet's teeth that will significantly reduce the rate of tartar build up, bad breath, and maintain the work done today. The additional cost is $34.08.

Post-Operative pain management: Your pet's comfort level is very important to us and appropriate pain management speeds up healing time. Pain management options for extraction sites and inflamed gums include:

Therapeutic laser, local anesthesia, long acting nerve blocks, injectable analgesics, constant rate drug infusions and oral medications to take home. The cost will vary and depend on individual patient needs, age and additional medical conditions.

I, the undersigned owner or agent of the pet identified above, authorize the staff of Chimney Rock Animal Hospital to perform the above procedure(s). *

I have read and understand

I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. (copy) *

I have read and understand

I understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life sustaining procedures. *

I give my permission (yes)
I do not give my permission (no)

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. A complete physical exam will be performed on your pet prior to the surgical procedure if it has been longer than 30 days since the last exam. However, this may not identify all systemic or metabolic problems. For this reason, your pet will have a pre-anesthetic blood panel to evaluate major organ functions prior to anesthesia. I have read and fully understand the terms and conditions set forth above. *

I have read and understand

Signature *

Today's Date *

Phone number(s) at which owner can be reached today or tomorrow: *

Name

Chimney Rock Animal Hospital

Dentistry Consent Form

Online Form

Dentistry Consent Form

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