Dentistry Consent Form

Complete Oral Health Assessment and Treatment

This procedure involves the removal of plaque and tartar both above and below the gumline, polishing of all tooth surfaces and full mouth dental radiographs (x-rays). The animal is placed under general anesthesia and will return home in the evening. The animal will receive intravenous fluids, which helps maintain blood pressure and allows for a better recovery along with venous access in the event of an emergency. The veterinary team will take dental X-rays and evaluate the state of teeth and gums, as well as all other oral surfaces. The veterinarian can then determine how many dental extractions are necessary (if any).

Follow up: If your pet had extractions, a recheck of the extraction sites is recommended in 14 days.

If your pet had a Fentanyl patch placed, this will need to be removed by veterinary staff in 3-5 days.

Which practice would you like to register with?

Location

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Full Name *

Best Phone Number

Address *

City *

Province *

Postal Code *

Email Address *

Alternative Contact Number

Pet's Name *

Pet's Date of Birth *

As the owner (or agent of the owner) of the animal described above I authorize and request Clayton Park Veterinary Hospital to hospitalize this animal for the purpose of a diagnosis, treatment, surgery or other procedures, as specified by this release and approve the use of the required anesthetics as prescribed by the attending veterinarian.

Your pet is being admitted for anesthesia/surgical procedure. To ensure your pet is in a low risk category prior to anesthetic we will be performing a blood profile. The blood profile is performed on site here at the hospital. This will enable us to have a base line reference prior to surgery and also act as a reference in the future should your pet become ill.

I, (the signee) understand that Clayton Park Veterinary Hospital will use reasonable caution to ensure my pets safety while it is in your care but will not hold Clayton Park Veterinary Hospital responsible if injury, escape or demise were to occur. By signing this document, I absolve Clayton Park Veterinary Hospital of liability for the procedure requested herein.

I understand that a more detailed examination under anesthetic may reveal further dental issues not anticipated on initial exam. Pet Focus - Clayton Park Veterinary Hospital will contact me with any changes to this treatment and or diagnostic plan as they arise.

I understand that payment is due at the time that services are rendered.

In the event that I am unavailable for contact and additional procedures may be deemed necessary at the discretion of the attending veterinarian:

Please select one *

I give consent for the additional procedures and I will be responsible for additional costs related to those treatments or diagnostics.
I do NOT consent to the additional procedures and I understand that this may lead to higher future costs and potentially delay treatment, which might not be in my pet's best interest.

Medications and Supplements

This includes medications for managing disease, human medications such as tylenol, supplements (fish oils, other joint supplements), etc.

Please provide a detailed list of the medications your pet takes. Please include the drug name, the amount your pet receives and how often your pet is given the medication.

Is your pet on any medications or supplements currently?

Yes No

Please write your pet's medications below:

When was the most recent access your pet had to food and water? *

Cardiopulmonary Resuscitation (CPR)

I understand that some risks exist with anesthesia and or surgery, including death, even in apparently healthy animals and I am encouraged to discuss my concerns regarding these risks prior to the procedure. Should some unexpected life saving emergency care be required, I request the following actions be taken:

CPR Consent *

Attempt to resuscitate my pet through use of chest compressions, medication administration, artificial respiration deemed appropriate by the attending Veterinarian.
Do not resuscitate. I understand that if no life-saving measures are taken, my pet will pass away.

- I accept that if the staff are unable to reach me within 15 minutes after CPR has been initiated and after exercising reasonable medical judgement, is determined there is still no signs of life, the staff will cease further CPR procedures.

- I understand that despite the best efforts of the veterinarian and staff, even the most successful CPR that restores my pet's life, may not allow for my pet to regain their normal mental and physical health.

Signature *

Today's Date *

Today

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

Dentistry Consent Form

Complete Oral Health Assessment and Treatment

Which practice would you like to register with?

Medications and Supplements

Cardiopulmonary Resuscitation (CPR)

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