Client First Name*

Client Last Name*

Pet's Name*

Preferred contact method day of procedure*

Text message

Phone Call

Phone number where you can be reached on the day of the procedure*

An estimate was provided to you for the dental procedure with a range of
potential extractions. Once your pet is under anesthesia and a complete oral
exam is performed with full mouth radiographs, we can get a more accurate
number of extractions necessary. If additional extractions are deemed necessary
beyond the estimated amount, you will be called to discuss an updated plan.

Was an estimate provided to you?*

Yes

Do you consent to the potential number of extractions?*

Yes

Pre-operative blood work is required for dental procedures. This blood work
allows our team to assess your pet’s anesthesia risk level and tailor the
medications used accordingly. While it is preferable to do it prior to the day of
surgery, we can perform this on the morning of surgery. It is best to have blood
work completed within 1 month of the procedure, but blood work completed
within 90 days will be accepted.

Canines Only: An up-to-date heartworm test is required for all dogs 1 year of age or older.
If your dog is overdue, we will update it on the day of surgery.

Pre-operative bloodwork is REQUIRED for all dental procedures. Has this already been performed for your pet?*

Yes

If No, this can still be performed in hospital, the morning of surgery if necessary.

Do you have any additional questions to go over with the technician during the time of your pet's surgical check in?*

Yes

In the unlikely event that your pet experiences respiratory and/or cardiac arrest
there is a short and critical window of opportunity to initiate CPR beyond which
the success rate of cardio-pulmonary resuscitation decreases significantly.

If CPR is selected and necessary, we will contact you to make further decisions.

If CPR is effective, there are often problems that need to be addressed after
resuscitation. CPR does not resolve any underlying diseases. It is important that
you know there are costs associated with CPR and the total will vary depending
on your animal’s needs. This and the cost of any additional care after CPR are in
addition to your current estimate.

Should you change your mind at any point during your pet’s hospitalization,
please notify your pet’s doctor so that we may follow your wishes. We will ask you
to sign a new form with your revised choice.

Would you like us to start CPR immediately or do you elect not to resuscitate (DNR)*

CPR

DNR

A noninvasive therapeutic laser is offered to all our dental patients. This is
performed over the gingival tissue (gums) after the completion of the cleaning. It
can be used for patients with or without extractions. This therapy helps decrease
pain, inflammation and speeds the healing process.

Laser?*

Yes

Is your pet currently on any medications?*

Yes

If yes, list medications and when last given*

By signing below, you have read and understand the additional information regarding dental procedures and consents for your pet’s procedure.

Signature*

Date*

Name

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Dental Check-In