Dental Consent Form CLICK HERE to Print the Dental Consent Form OR fill out and submit the electronic version below Dental Consent Form Pet’s Name*Pet Owner/Authorizing Agent Name*Email* Phone Number at which I can be reached immediately and at all times today*Name of Procedure(s)i.e. Dental Cleaning and Polishing During this Procedure: I give permission to do what is medically necessary, including removal of diseased tooth/teeth. I am placing no restrictions on the medical team regarding removal of teeth and give permission for the doctor to remove any/ all necessary. I do NOT give permission to do what is medically necessary regarding removal of teeth at this time. If the doctor performing the dental procedure feels it is necessary to remove any tooth/teeth, it is my wish that the doctor call me to discuss extractions prior to removing teeth. Please realize the doctor cannot make the decision as to whether any teeth need to be removed until your pet is anesthetized and the dental cleaning is in progress. If you elect to have the doctor call you prior to extracting any tooth/teeth it is essential that you answer our call immediately. Failure to answer our call may mean that the dental procedure is completed prior to speaking with you and no extractions are performed. I UNDERSTAND THAT MY PET MAY HAVE TO UNDERGO ANOTHER ANESTHETIC PROCEDURE TO ADDRESS DENTAL PROBLEMS IF CONTACT WAS NOT POSSIBLE. I ACCEPT ALL RISKS AND FEES ASSOCIATED WITH ANOTHER PROCEDURE SHOULD SUCH AN EVENT OCCUR. Estimated Cost/Fees for Routine Dental Cleaning & Prophylaxis Procedure --- $251.00 Estimated cost/Fees for Fluids, subcutaneous or Intravenous --- $45 - $90 Estimated Cost/Fees for tooth removal (extraction) vary with type of tooth removed, difficulty of extraction(s), and number of extractions --- $25 - $100 PRE-ANESTHETIC BLOOD TESTING Before placing your pet under anesthesia, we will perform a physical examination. However, many conditions, including disorders of the liver, kidney, or blood, are not detected unless blood testing is performed. Such tests are especially important before any kind of surgery. For these reasons, we highly recommend blood screening before such procedures. Please choose one of the following: Yes, I want my pet to have a FULL pre-anesthetic blood screen at a cost of $170.69 (full chemistry and CBC)$170.69I give permissionI do NOT give permissionYes, I want my pet to have a BASIC pre-anesthetic blood screen at a cost of$65.55I give permissionI do NOT give permissionNo, I do not want my pet to have a pre-anesthetic blood screen.No pre-anesthetic blood screen.MICROCHIPPINGMicrochips are small identification chips implanted under your pet's skin. Each chip has a unique number connected to your information. This can be done painlessly while under anesthesia today. Please choose one of the following:Yes, I would like my pet to receive a HOMEAGAIN microchip for $54.39. This includes the microchip, one time registration fee and a 1 year membership.No, I do not authorize my pet to be microchipped todayMy pet is already microchippedCONSENT AND PAYMENTIt is possible that other fees might be incurred today including antibiotics or other medication(s) as well as fees for other procedures performed, at the request of the client, during the anesthetic procedure. I understand that the procedures agreed to above will be performed under general anesthesia for my pet today. I am aware of and accept all risks associated with these procedures and I agree to hold harmless the medical team should unanticipated liability arise out of the performance of the procedures above. I agree to pay all charges for today's procedures when my pet is released from the hospital.* I Agree Signature Field ("sign" your name by typing your name in the field)CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.