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Dental Consent Form
Date
*
Date Format: MM slash DD slash YYYY
Client Name
*
First
Last
Pet's Name
*
First
Owner's Date of Birth
*
Date Format: MM slash DD slash YYYY
Dental Patient History
The Date and time of pet's last meal:
*
Date Format: MM slash DD slash YYYY
Date of Last Blood Panel
*
Date Format: 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 Information
We 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 Release
I 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:
*
