Dental Consent Form If you prefer to print this form, click here. Date* MM slash DD slash YYYY Client Name* First Last Pet's Name* First Owner's Date of Birth* MM slash DD slash YYYY Dental Patient HistoryThe Date and time of pet's last meal:* MM slash DD slash YYYY Date of Last Blood Panel* MM slash DD slash YYYY A blood panel is required to be performed within 30 days of any anesthetic procedure. If it has been greater than 30 days, I am aware a blood panel will be performed in hospital at an additional charge. A pre-anesthetic electrocardiogram (ECG) is recommended to evaluate your pet's heart prior to anesthesia. Please select one of the following:* An ECG has already been performed within the last 30 days. Please perform an ECG today. I am aware this will incur an additional charge. Decline ECG Today Has your pet received any medication in the last 24 hours? Please list below:Has your pet ever had a seizure? Yes No Please select if your pet has had any of the following:* Coughing Sneezing Vomiting Diarrhea Runny Eyes No, my pet has not had any of the above symptoms Estimate InformationWe have prepared an estimate for the planned procedures. This is only an estimate. Once we have your pet under anesthesia we will be able to better assess your pet's dentistry needs; please be available as we may need to re-evaluate the dental plan and discuss further treatments. We will always strive to keep you updated and work together to decide what will be best for you and your pet. In the event that we are unable to contact you while your pet is under anesthesia we would like to know how we should proceed.Please select one of the following* I consent to only the work as previously estimated for and discussed I consent to proceed up to a certain amount and I will assume all financial responsibility I consent to proceed at your discretion, I assume all financial responsibility This is the max amount I am willing to consent to:* Please enter dollar amount.Consent* I agree to the Dental ReleaseI hereby consent and authorize the Doctors and staff of Brighton Greens Veterinary Hospital to proceed with the dental procedure and anesthesia as previously discussed, I do understand that this procedure may or may not involve extractions. Hospital policy requires that 100% of the estimate be paid upon admission to the hospital. The balance is due in full upon release from the hospital. I understand that there is no attendant or Veterinarian in the hospital after business hours.Please type your name acknowledging the above release.* Phone number you can be reached at today:* Δ
