Forms 7 and Over Dental Consent Form EmailThis field is for validation purposes and should be left unchanged.DENTAL CONSENT FORM*for patients 7 years of age or older*Admission Date (Procedure Date)(Required) MM slash DD slash YYYY Owner's Name(Required) First Last Phone Number(Required)Please enter a valid phone number.Pet's Name(Required)Breed of Pet(Required)Pet's Age(Required)Animal Sex(Required)Color of Pet(Required)Surgical Procedure being performed today?(Required)Do not feed your pet after 10pm the night prior to surgeryInitial Here(Required)Please list all medications that the animal is currently taking(Required)Do not give medications the morning of surgery unless otherwise instructed to do so by the doctor or technicianInitial Here(Required)CONSENT FOR ANESTHESIAI hereby consent to the use of anesthesia and any therapeutic drugs deemed proper by the veterinarian. I understand the inherent risks of a surgical procedure and agree that I will not hold Fredericksburg Equine & Small Animal Veterinary Services,veterinarians and/or staff, responsible for any surgical or post-surgical complications.Initial Here(Required)PRE-ANESTHETIC BLOODWORK AND IV CATHETER & FLUIDSA pre-anesthetic blood screen includes a panel of chemistries checking the liver, kidneys, glucose, and total protein levels. This screening includes a CBC (complete blood count) to check for abnormalities in the red and white blood cells. Pre-anesthetic bloodwork is required for all patients 7 years or older.IV CATHETER AND FLUIDSAn IV catheter and fluids provide valuable cardiovascular support for patients under anesthesia and promotes post-surgery recovery. An IV catheter and fluids are required for all patients 7 years or older.Dental FindingsDuring teeth cleaning procedures, unexpected finding often occur within the pet’s mouth. Examples of this include diseased or infected teeth that need to be extracted and/or oral growths or tumors that need to be surgically removed. We will make every effort to contact you to inform you of any abnormal findings resulting in the change in the cost of treatment. Additional costs may vary depending on the difficulty of extractions, etc. (See estimate for price levels.)In the event we cannot reach you to discuss abnormal dental findings:(Required) I authorize for the doctor to proceed with necessary extractions or tumor removals. I understand that additional costs may be incurred. I do not authorize the doctor to proceed with dental extractions or tumor removals if I cannot be reached via phone. CARDIOPULMONARY RESUSCITATION (CPR)In the unexpected event of cardiopulmonary arrest, resuscitation (CPR) techniques may be used if approved by client. These techniques would only be used in the event of a life-threatening situation. = $300Cardiopulmonary resuscitation in the event of a cardiac emergency(Required) I ACCEPT I DECLINE TAKE-HOME PAIN MEDICATION AND ANTIBIOTICSInjectable pain medication will be administered to every patient undergoing a surgical procedure (included in surgery cost). Depending on surgical findings, the doctor may also prescribe take-home pain medication and antibiotics. The cost of take-home pain medications and antibiotics is not included in the surgery price. Initial Here(Required)ADDITIONAL SERVICESADDITIONAL SERVICES Heartworm Test ($35.00) Microchip ($45.00) Nail Trim ($15.00) Tattoo ($5 – Outwardly shows an animal is spayed or neutered) Feline Ear Tip (Free – Outwardly shows an animal is spayed or neutered) VACCINATIONS Rabies ($16) Bordetella (kennel cough) ($36.73) DHLPP ($29.50) Rattlesnake vaccine ($29.52) Proheart injection (6 or 12 month heartworm prevention – price varies by weight) FVRCP/FELV vaccine ($50.15) FELV test ($56.58) Signature(Required)Today's Date(Required) MM slash DD slash YYYY
