Name *

First

Last

Email *

Phone *

Today's Date *

Date of Surgery *

Pet's Name *

As the owner or agent of the above animal, 18 years of age or older, I hereby give my consent to West Russell Animal Hospital to perform a dental cleaning on my pet. *

I agree.

Like you, our greatest concern is the well-being of your pet. Prior to administering anesthesia to your pet, a full physical exam is performed. Included in the price of each dental is (1) an intravenous catheter and fluid therapy and (2) state of the art anesthesia monitoring.

Are vaccinations current? (Required for admission) *

Yes
No

Has your pet ever had seizures? *

Yes
No

Any coughing, vomiting, or diarrhea? *

Yes
No

Any illness in the past 30 days? *

Yes
No

Did your pet eat this morning? *

Yes
No

Would you like a microchip? *

Yes ($45)
No
Already has one

Pre-surgical blood testing is recommended to help reduce the risks involved with anesthesia. This test checks the internal status of your pet, including liver and kidney function (these are the main organs that metabolize anesthesia, complete blood count, and blood glucose level. Please select an option below if you'd like to add pre-surgical blood testing.

Pre-anesthetic panel with CBC (recommended for pets under 7 years) - $127
Comprehensive chemistry panel with CBC (required for pets over 7 years) - $169

Many dogs experience vomiting following the administration of some anesthetic drugs. Cerenia can help prevent vomiting on the day of surgery, as well as help them return to normal feeding sooner. This injection is an additional $72.00-$95.00. Would you like this for your pet? *

Yes
No

If your pet's doctor deems extractions are neessary, we will attempt to reach you at the number you have provided and give you an estimate for the additional cost. If we are unable to reach you at the phone number you provided, and your pet's doctor deems extractions are necessary, please select one of the following: *

APPROVE: I approve all necessary dental procedures needed at this time. I accept full responsibility of financial charges associated with this decision.
CALL BEOFRE: I would like to be called before any extractions are done. If I cannot be reached, I do not authorize the staff at West Russell Animal Hospital to proceed. A detailed treatment plan will be provided to me at the time of discharge.
DO NOT CALL: I would not like to be called for any additional procedures, other than an emergency situation. Do not perform any additional dental work. A treatment plan will be provided to me at the time of discharge.

CPR *

Yes. Cardiac Circulatory Pulmonary Resuscitation: I understand that risks and potential complications exist with anesthesia surgery and do not hold West Russell Animal Hospital liable for those risks. The attending veterinarian will perform any necessary emergency care and I agree to assume all financial responsibility associated with my decision.
No

In the event any adverse medical probelms occur because of my decision to not treat my pet's dental issues, I accept full financial responsibility and I hereby release West Russell Animal Hospital and all staff members of all responsibility for my decision. I understand payment is due in full at the time of discharge. By clicking 'I agree' I indicate that I understand this consent and I have an agreement with West Russell Animal Hospital. *

I agree

Signature *

Please type your name.