Dental Consent Form - Gentle Care Animal Hospital at Tryon Rd.

Owner Name*

First Last

Client ID

Animal name*

Breed

Age*

Sex*

Appt Date*

Last meal eaten*

Special diet or dietary restrictions

Current medications and time last administered*

Please list any known allergies or adverse reactions to medication(s)*

Dental services performed for your pet today include:

Thorough oral cavity exam
Probing and charting of all teeth and any abnormalities
Scale and polish teeth
Dental x-rays
Formulate a treatment plan to address any problems found

*

I give my permission for my pet to be anesthetized for a dental cleaning

*

I understand that in order for my pet to undergo anesthesia and stay in the hospital they must be current on all vaccines and must have recent bloodwork assessing organ function.

*

I understand that even with excellent care and precautions, rare adverse reactions or events can occur with anesthesia. These events are extremely rare and can include but are not limited to: cardiac arrest, respiratory arrest, and death.

*

I understand that an IV catheter will be placed and a small area on the leg will be shaved for placement

In the event that abnormalities that require further assessment or treatment are found, I authorize Gentle Care Animal Hospital to perform (please choose one):

Any and all extractions/treatments deemed necessary.
The extractions/treatments detailed in the provided estimate but please call if any additional extractions are needed.
No extractions/treatments without contacting me first.

*

If extractions go beyond what I have authorized, I wish to be contacted first. I understand that I must be available at all times by phone and if Gentle Care Animal Hospital cannot contact me my pet will be recovered and additional procedures will need to be scheduled for another day.

MICROCHIP: Would you like your pet to have a microchip placed while under anesthesia? ($66.40 with surgery)*

Yes
No
I already have one

Phone number where you can be reached between 8:30 a.m. and 3:30 p.m.*

Please provide an email address or cell number if you would also like an email or text update when your pet is awake

I have read and understand the information above:*