*NO WATER AFTER 8:30AM THE DAY OF SURGERY*

*NO FOOD AFTER 12AM THE NIGHT BEFORE SURGERY*

Briarcliff Animal Clinic Too

1662 Virginia Avenue, College Park, GA 30337

404-835-1222

www.collegeparkvet.com

Dental Admission Form

Client Name______Date: ______

Patient Name______

Procedure______

Phone Number(s)*______

*It is very important that we are able to reach you during the procedure to make timely decisions in your pet’s course of treatment.

-I do hereby authorize Briarcliff Animal Clinic Too to perform a dental procedure under general anesthesia, and declare that I am the legal owner or authorized custodian of this animal. I release Briarcliff Animal Clinic Too or representatives of all legal responsibility for this animal.

-I am aware of the risks involved in anesthesia. I understand that anesthetic or surgical complications may occur, potentially resulting in medical problems or even death.

Pre-Anesthetic Bloodwork

Briarcliff Animal Clinic Too requires pre-anesthetic bloodwork to identify any underlying medical problems that may cause complications with your pet’s anesthesia.

A CBC & Chemistry Profile (Glucose, BUN, Cr, ALP, ALT, TP) will be performed at a cost of

$108.75 unless it has been completed within 90 days of the procedure and are available for the

Veterinarian’s interpretation.

Pain Management: It is the ethical standard of this hospital to provide pain management to every pet before, during and after surgery. An injection will be administered to your pet prior to surgery and during the procedure to minimize your pet’s discomfort. We may also provide oral pain medications for you to give at home.

IV Catheter and Fluids are required for all surgeries

During the procedure, additional problems may be discovered.

Permission is granted to:

Dental x-rays are used to assess any potential disease below the gum line. Please choose one of the following options:

□ Take dental x-rays and evaluate them to determine if any treatment is necessary. (Recommended)

(Full mouth radiographs are $108.50)

□ Take dental x-rays only if an abnormality is detected on oral exam.

□ Take no dental x-rays, regardless of findings.

Oravet dental sealant is available for application after the dental cleaning. This product helps prevent plaque and tartar build up. A take-home kit is available for purchase after the procedure and should be applied weekly.

Please apply Oravet dental sealant after the dental cleaning for a charge of $24.50. Yes No

Please send me home with an Oravet take-home kit for a charge of $56.90. Yes No

Please place a microchip in my pet during sedation of a charge of $85.00. Yes No

We offer a complimentary nail trim while your pet is under anesthesia. Yes No

Signature ______Date______