"*" indicates required fields Owner’s InformationName* First Last Pet’s InformationName* Breed* Age* Date of scheduled dental* MM slash DD slash YYYY Please complete the following form allowing American Veterinary Hospital to perform a dental procedure on your pet. We ask that you read the form in its entirety and acknowledge each statement. If you have questions or concerns regarding this form please contact our practice directly. Rabies Vaccination - I understand a Rabies vaccination is required for pets 16 weeks and older Fasting (withholding food) - I certify that the above animal has not been fed since last evening & fasting instructions were followed After Hours Care - Pets are expected to be released at the end of the business day, however if the doctor deems necessary he may recommend the pet stays overnight for a quiet and secure recovery. I understand that no one is on the premises after hours IV Catheter / Fluid Therapy - An intravenous catheter (IV) is placed giving direct access to the pet’s vein in the event of a crisis. Fluid therapy is also administered through the IV throughout the surgical procedure for anesthesia safety and maintaining a steady blood pressure. I understand my pet will be shaved where the IV is placed. Blood Work - A comprehensive blood work profile is required for every pet undergoing sedation, regardless of age. This profile was performed prior to your scheduled dental procedure date, unless deemed by the doctor as an emergency.Please choose one* Results of bloodwork were explain to me and I am choosing to go forward with the procedure I understand if the preanesthetic profile was not taken prior to the pet’s scheduled sedation date. It will be done prior to anesthesia being administered Extractions - Depending on the condition of your pet's teeth, extractions may be necessary. The doctor will access your pet’s teeth and determine if a tooth needs to be extracted or repaired. Due to the nature of the procedure, we are unable to notify owners if extractions or cavity fillings are needed at the time of the dental. Extractions are performed at an additional cost. $35 - Easy extraction $90 - Difficult Extraction I understand by signing this document, I acknowledge the possibility of extractions or repairs being performed at the doctor’s discretion. CPR / DNR Permission - Every effort is made by our practice to ensure the safety of the medical procedure when using sedation /anesthesia. I acknowledge there are always risks involved and the possibility of complications in any procedure.* In the event my pet goes into cardiac/ respiratory arrest (heart stops/ stops breathing) I give permission for American Veterinary Hospital to perform CPR and other lifesaving measures. NO, I do not wish for any lifesaving measures to be taken. As the owner, or authorized agent of the above named animal, I hereby consent and authorize American Veterinary Hospital to receive, prescribe, treat, and operate on my pet. The nature of the procedure(s) being performed has been explained to me and no guarantee has been made as to the results or cure. I understand that the practice staff and doctors will make every effort possible to minimize the risk associated with general anesthesia and the services to be performed, however all risks will be assumed by me. I have read, fully understand, and agree to the above. I understand that all fees must be paid before my pet is released from the hospital. I understand a written estimate of anticipated fees has been or will be provided for me upon request. Signature of owner/agent*Date* MM slash DD slash YYYY Contact Number*PhoneThis field is for validation purposes and should be left unchanged.
