Dental Procedure Consent Form CLIENT*PATIENT:Name*HISTORYIs your pet allergic to any medications?* Yes No If Yes*MEDICATIONLAST GIVEN Any history of seizures and/or previous aesthetic problems?* Yes No Is your pet currently on any medications?* Yes No If yes, what is he/she taking?" "What dose and last given?*MEDICATIONLAST GIVENTIME Did you receive a pre-op care package?* Yes No If yes, please fill out the following*MEDICATIONLAST GIVENTIME Please withhold food after 8pm the night before and the morning of the procedure, water is ok.Is your pet vomiting?* Yes No Does your pet have diarrhea?* Yes No Would You like us to update any past due vaccines during your pet's visit?*Current Rabies Vaccine is mandatory, the vaccine will be given if no proof of a current vaccine is provided. Yes No if Yes, please describe*Is your pet on a heart-worm preventative?* Yes No If no, would you like us to get them started today?* Yes No Is your pet currently using flea prevention products?* Yes No If no, would you like us to get them started today?* Yes No Is your pet microchipped?* Yes No If no, would you like to have us insert one?* Yes No PROCEDURE TO BE PERFORMED TODAY: Pre-anesthetic bloodwork and urinalysis will be done on your pet before anesthesia to check the overall health of your pet’s organs (Please note that if your pet is 2 years of age or older blood work is mandatory). We also place IV catheters to administer IV fluids throughout the procedure for maintenance of proper blood volume and faster recovery. Due to increased risks of some patients the doctor may refuse to perform the procedure if pre-anesthetic bloodwork is declined.* I DO give permission for the for doctor and staff to run pre-anesthetic bloodwork, urinalysis and place an IV catheter I DO NOT give permission for the doctor and staff to run pre-anesthetic bloodwork, urinalysis and place an IV catheter Would you like us to use post-operative laser therapy to accelerate healing? Yes No EXTRACTION CONSENTIf the dental estimate is exceeded during the procedure and additional extractions are deemed necessary:* I DO give permission for the doctor and staff to extract the additional teeth at an additional cost. I DO NOT give permission for the doctor and staff to extract the additional teeth. CPR/DNRIn the event that your pet should experience cardiac or respiratory arrest while boarding, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of your pet's status?By consenting to this service, you are also acknowledging that certain charges will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion.* I agree to CPR being performed in case of arrest and agree to any financial obligations as a result of CPR being performed regardless of outcome. I elect a “Do Not Resuscitate” status in case of arrest. PHONE NUMBER(S) WHERE YOU CAN BE REACHED TODAY*If you cannot be reached at the phone number provided above, we will not proceed with the procedure or treatment. This can cause delays in pick-up times, and our ability to treat your pet. You will be still be charged for any services performed.OWNER RELEASE AND CONSENTMVVH Orland, Inc., doing business as Mid-Valley Veterinary Hospital, will use all reasonable precautions against injury, escape, or death of your pet. I understand that anesthesia and surgery always involve some risk to your pet and agree to hold Mid-Valley Veterinary Hospital harmless, in the absence of negligence, in connection with these procedures. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. In the event complications arise and I cannot be immediately contacted at the below-listed phone number, Mid-Valley Veterinary Hospital is directed to make the decision(s) it deems best for my pet. I have read the foregoing, understand what it says, and agreeA DEPOSIT OF 50% OF THE COST OF THE TREATMENT PLAN IS DUE AT THE TIME OF PATIENT DROP OFF FOR ALL SURGERIES AND EMERGENCIES. I ACKNOWLEDGE THAT ANY REMAINING BALANCE IS DUE AT TIME OF DISCHARGE.Signature*Date* MM slash DD slash YYYY PHONE NUMBER(S) WHERE YOU CAN BE REACHED THROUGHOUT YOUR ABSENCE*
