Dental Drop Off – Fill Out Online

Agreement

When any dental procedure is being performed, it is important to know the degree of periodontal disease. This is often best assessed when the pet is under anesthesia. At this time, diseased teeth are often found which could require extractions. Please initial the line below to authorize the extraction of any diseased tooth.

Do whatever is needed to give my pet a healthy mouth. *

Yes No

Call me for approval of any procedure or extraction not previously discussed with me or included in my dental estimate. If I cannot be reached, I understand that my pet will be awakened and a second anesthesia and dental may need to be scheduled. *

Yes No

Do not do any procedures beyond what has already been estimated and approved by me. I understand that my pet will be awakened from anesthesia.

Yes No

Our greatest concern is the well-being of your pet. The doctor will perform a physical examination before administering anesthetic agents. Anesthesia does carry some risk, even for routine surgery. Circle B Veterinary Hospital’s doctors and staff utilize a safe anesthetic protocol unique to each patient. All patients will receive pre-anesthetic bloodwork, including coagulation times, an IV catheter, IV fluids, and postoperative pain medication if indicated.

What medications is your pet currently taking and when was the last time it was given? Refills? *

When did your pet last eat?

Any known allergies or reactions to vaccines or medications?

Yes No

Do you want a microchip ($50)? Nail trim under anesthesia ($6)?

Yes No

Preferred pick up time:

Waiting outside Pickup time

Are there any other concerns or questions you may have? *

Yes No

If there are any complications (if your pet is severely ill or has a life-threatening reaction) please select one if we CANNOT reach you for decision. *

CPR DNR (do not resuscitate)

We are here to help you with anything you need

Agreement

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