Dental Consent CONSENT FORM DENTISTRY SERVICESBrook-Falls Veterinary Hospital & Exotic Care Patient Name First Client Name First Last I am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consent. I hereby give the doctors of Brook-Falls Veterinary Hospital & Exotic Care Inc., and any authorized agents, staff, or representatives consent to perform the following procedures or operations: general anesthesia, IV fluids, complete oral exam, full mouth radiographs, teeth cleaning and polishing, and bonded dentin sealants for chipped crownsAdditional procedures to be performedWe do not know the extent of oral disease present in your pet's mouth until a complete oral exam and full mouth radiographs have been taken under anesthesia.Therefore, I give permission for oral surgery for extractions and gingival lesions/masses and pain medications if necessary up to the upper end of the treatment estimate.YesNoCALL ME FIRSTIf you cannot be reached, we will not proceed with the procedures and your pet will need another anesthesia to finish the necessary treatments at additional cost. We are able to provide restoratives for uncomplicated crown fractures and cavities (price varies). We will contact you if these are indicated. We recommend SANOS dental sealant after the teeth are cleaned and polished. This seals the gumline area of the tooth helping to prevent gingivitis, calculus and bone loss at the gum line for 6 months. The cost of the sealant is $100. In 6 months, it can be applied again with your pet under a mild sedative. I wish to have SANOS dental sealant applied to my pet's teeth today.YesNoI received a treatment plan for today's procedure within the range of$1-$500$500-$1000$1000-$2000$2000-$3000$3000-$4000$4000-$5000$5000+This is an estimate only. If the total charges exceed the high end of the treatment plan by more than 10%, we will consult you before administering further treatment. If you have any questions, please discuss this with your veterinarian before treatment is provided. The nature of these operations or procedures has been explained to me, and I understand what will be done. I have been informed that there are certain risks and complications associated with any operation or procedure of this type, and that during the course of the procedures unforeseen conditions may arise that may necessitate the performance of additional procedures. I authorize the use of appropriate anesthesia and pain relief medication as needed before or after the procedures. I understand that hospital support personnel will be used as deemed necessary by the veterinarian. Name to call with update: First Last PhoneDate Date Format: MM slash DD slash YYYY To receive updates today on my pet, I prefer a:TextPhone CallAdditional QuestionsDo you wish to have your pet receive a Home Again Microchip?YesNoAlready HasHas your pet eaten anything at all in the last 12 hours?YesNoHas your pet been given any medications, supplements, or treatments during the past 7 days?YesNoIf the answer above is yes, please list all such medications or treatments :Has your pet ever had a past anesthetic event that you thought went Poorly?YesNoDo you have any questions for the Doctor this morning?YesNoDo you need any medications refills today?YesNoDo you think you will be able to brush your pet's teeth once daily long term?YesNoDental home care is extremely important to keep your pet's mouth clean and healthy after the dentistry today. At discharge we will discuss the recommended dental products for your pet.What products do you currently have at home and how often are they used: pet toothpasteHow many times a week?oral rinseHow many times a week?dental dietHow many times a week?dental treatsHow many times a week?dental chewsHow many times a week?dental food additivesHow many times a week?dental water additivesHow many times a week?Which product would you like to receive at no charge with your procedure today? Toothpaste Dental treats Dental chews Dental food additive Dental water additive
