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 any teeth. Please realize that 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 tooth removal (extraction) vary with type of tooth removed, difficulty of extraction(s), and number of extractions --- $25-100 Estimated cost/fees for fluids, subcutaneous or intravenous --- $45 - $90 Other Recommendations and Fees frequently associated with Dental WorkI would like my pet to have full blood screen (complete blood counts, full chemistry panel) Recommended for pets 7 years and older or pets with chronic medical conditions such as diabetes, kidney disease, thyroid, etc. In some situations, these tests may be required before anesthesia and dental procedure.$148.17I give permissionI do NOT give permissionInstead of full blood screen, I would like my pet to have mini pre-anesthetic blood work (screening tests for anemia, kidney disease, liver disease and dehydration)$57.00I give permissionI do NOT give permissionMICROCHIPPINGMicrochips are small identification chips that can be implanted under your pet’s skin. Each chip has a unique identification number that is connected to your information. This can be done painlessly for your pet while they are under anesthesia today. Please choose one of the following:Yes, I would like my pet to receive a HOMEAGAIN microchip at a cost of $54.39. This includes the microchip, one time registration fee & 1 year membership.No, I do not authorize my pet to be microchipped todayMy pet is already microchippedIt is possible other fees may be incurred today including antibiotics, 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 FOR IN-OFFICE USE ONLY: Signature FieldNameThis field is for validation purposes and should be left unchanged.