EDINBURG ANIMAL HOSPITAL

DENTAL PROPHY ADMITTING FORM

Owner’s Name______Pet’s Name______Age______

Pet History: Are vaccinations current? Yes / No / Please Update

Did your pet eat anything this morning? ______

Any history of seizures or any other medical issue?______

Is your pet allergic to any drugs?______

Is your pet currently on any medication?______

Any other specific problems to be checked?______

Elective procedures to be done at the same time:

Ear cleaning ______Empty Anal Glands ______Nail Trim ______Microchip ______

Apply Topical Flea Treatment ______(automatic if fleas seen)

PRE-ANESTHETIC SCREENING CONSENT / WAIVER

Like you, our greatest concern is the well-being of your pet. A physical exam will be performed

before anesthetizing your pet. However, many conditions, including disorders of the kidneys, liver, and blood, cannot be detected without further testing. For these reasons, our

recommendation is to perform pre-anesthetic testing (CBC / chem 10 panel) on all

animals, and provide intravenous fluid support while under anesthesia. There is an additional charge for these services. If you would prefer an option below, please check off and initial:

______I authorize limited labwork only (Chem 10 / CBC)

______I authorizeintravenous fluids only

I refuse all of the above. Please initial______. **Owner Release: I understandand assume all responsibility for additional risks or complications resulting from refusal to approve these screening procedures.

EXTRACTION & OTHER PROCEDURES CONSENT / WAIVER

Pets require anesthesiafor a thorough examination to be completed. The condition of each tooth must be evaluated before a decision is made as to the best course of treatment. Although no one likes surprises, it often is impossible to give an accurate estimate before anesthesia. In an effort to accommodate you, please initial the appropriate option below:

______Please perform whatever procedures & extractions are required at this time.

______Please do nothing more than the requested dental prophyprocedure at this time.

______Please call me after the exam with an estimate if any additional procedures are needed. *If wecannot reach you, we will not proceed. Any recommended procedures would then need to be rescheduled.* If any extractions are performed, your pet will also receive pain management and medications sent home, all of which may be in addition to your estimate.

Owner Release:

You are to use all reasonable precaution against injury, escape, or death of my pet. I acknowledge that no guarantee has been made to me as to the results that may be obtained. I understand that any anesthetic procedure involves some risk to my pet, up to and including death. In the event complications arise and I cannot be immediately contacted at the listed phone number, you are directed to make the decision you deem best for my pet. I agree to pay for all services rendered upon discharge. I have read the foregoing, understand what it says, and agree.

Signature(owner/agent)______Date______

Phone number where I can be reached today:______