(530) 865-5634 |  4422 County Rd N, Orland, CA 95963 | M-F: 8:00am - 5:30pm

Mid-Valley Veterinary Hospital

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Dental Procedure Consent Form

  • PATIENT:

  • HISTORY

  • MEDICATIONLAST GIVEN 
  • MEDICATIONLAST GIVENTIME 
  • MEDICATIONLAST GIVENTIME 
  • Please withhold food after 8pm the night before and the morning of the procedure, water is ok.
  • Current Rabies Vaccine is mandatory, the vaccine will be given if no proof of a current vaccine is provided.
  • 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.
  • EXTRACTION CONSENT

    If the dental estimate is exceeded during the procedure and additional extractions are deemed necessary:
  • CPR/DNR

    In 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.
  • 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 CONSENT

    MVVH 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 agree

    A 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.

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