Dental Form

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Dental Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet before your visit.

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Just fill out and send to our team at northgateanimal.xray@gmail.com.

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NORTHGATE ANIMAL HOSPITAL DENTAL ADMITTING FORM

OWNERS CONSENT FOR ANESTHESIA AND TEETH CLEANING

Date *

Client Name *

Phone Number *

I consent to receive SMS text messages from Northgate Animal Hospital. Msg & data rates may apply. Reply STOP to opt-out. *

Pet Name *

Procedure *

Drop Off And Pick Up Times

Drop off is at 7:30AM. Please note the clinic and doors open at 7:30AM.
Bring your pet with this completed form.
Please bring all your pet's medication and any records, radiographs, etc.
All pain medication for your pet will be prescribed if needed, and will be an additional fee to the surgical cost on your final bill.
Your pet will need to be picked up by 6:00 PM unless otherwise notified or your pet is hospitalized overnight.

BLOODWORK

We recommend that pets under 7 years of age have pre-anesthetic blood test done prior to any anesthetic surgery. This test is a mini-chemistry panel and PCV blood test. If you would like to authorize these tests to be performed, an additional fee of $74.85 will be added to your final bill. *

I authorize the preoperative blood tests.
I do not authorize the preoperative blood tests.

*We REQUIRE that pets over 7 years of age and over have pre-anesthetic blood work blood tests done prior to any anesthetic surgery. This test is a Chemistry Panel and PCV blood test. This pet will also be placed on IV fluids during the surgical procedure per the hospital's surgical protocols. The total cost of these treatments are $206.75.

LASER SURGERY

Laser surgery reduces pain, tissue swelling, and bleeding during and after the surgical procedure. This procedure is available for an additional fee of $92.80 *

I authorize the laser surgery.
I do not authorize the laser surgery.

*ALL DECLAW SURGERIES ARE REQUIRED TO BE DONE WITH THE SURGICAL LASER, NO EXCEPTIONS CAN BE MADE WITH DECLAWING.

CURRENT MEDS

Please list any current medications below, when they were last given, what time they were given, and how often you administer them. Please bring any medication you were not able to give today. *

ALLERGIES

Is your pet allergic to any medicines? Allergic to any food? If so, please list them below: *

EXTRACTIONS

Your pet is scheduled for a teeth cleaning today. This procedure includes general anesthesia, an oral exam, teeth cleaning. dental polishing and fluoride dental treatment. Dental radiographs are also required during this procedure to detect dental disease below the gumline or to verify that an extracted root is completely removed. The cost for dental radiographs range from $62.80-$145.20. After your pet's dental cleaning, our staff can sometimes find teeth that your pet may need to have additional care for, or have those teeth extracted. In the event that teeth need to be extracted (this also includes baby teeth) or another dental procedure that may need to be performed, our staff can call you, or you can preauthorize extractions if needed. *

If my pet's teeth need to be extracted, you have my permission to extract teeth without contacting me. I understand that there will be additional charges associated above the regular teeth cleaning fees.
I do not want to have any of my pets teeth extracted unless I am called and verbally authorize my pets dental extractions. I understand that if I am unable to be reached via the phone number that was provided today, I understand that my pets teeth will not be extracted during the dental cleaning and I will need to schedule another dental procedure to take care of the additional unhealthy teeth at a later date and time.
If my pet's teeth need to be extracted, you have my permission to extract teeth for an additional cost of up to (enter below)

***PLEASE HAVE YOUR PHONE AVAILABLE WITH YOU AT ALL TIMES WHILE YOUR PET IS WITH US TODAY IN CASE OF AN EMERGENCY OR IF DENTAL EXTRACTIONS ARE NEEDED.

BIOPSY

Biopsy *

Yes, I authorize a biopsy. ($172.00)
No, I do not authorize a biopsy.

VACCINATIONS

If your pet is coming due for any yearly vaccinations, would you like those updated while youe pet is here at an additional cost? *

I authorize vaccines to be given.
I do not authorize vaccines to be given.

FLEAS

Pets with fleas will be treated with an in-hospital product at an additional cost. If you have recently treated your pets for fleas, please inform us of what product was used and when you applied it. *

MICROCHIPPING

Microchipping your pet places and identification chip with a coordinating number under the skin. The number is then registered to you through Petlink, so in the event your pet is lost, it can help in returning them home. Lifetime registration is included with the cost of the microchip, so this means there is no additional fee to register your pet to the national database. The fee for the microchip is $54.00. The microchip fee normally is $60.00, this is discounted 10% for pets undergoing anesthesia. *

I authorize microchip placement for my pet.
I do not authorize microchip placement for my pet.

ADDITIONAL TREATMENTS

If our professional staff sees a medical problem that needs to be treated such as an ear infection, skin allergy, extraction of retained baby teeth, etc. do we have authorization to treat your pet appropriately? The additional treatments will be at additional costs. *

I authorize additional treatments. I understand that their will be additional charges associated above the regular surgery fees.
Please call first with an estimate before any additional treatments.
I authorize additional treatments UP TO a specific amount. Enter below.

*YOU MAY BE REQUIRED TO LEAVE A DEPOSIT BY TELEPHONE.

PLEASE ANSWER THE FOLLOWING QUESTIONS *

	YES	NO
Is your pet eating and drinking normally?	YESIs your pet eating and drinking normally? YES	NOIs your pet eating and drinking normally? NO
Is your pet weak or lethargic?	YESIs your pet weak or lethargic? YES	NOIs your pet weak or lethargic? NO
If your pet vomiting?	YESIf your pet vomiting? YES	NOIf your pet vomiting? NO
Does your pet have diarrhea?	YESDoes your pet have diarrhea? YES	NODoes your pet have diarrhea? NO
Does your pet strain when urinating?	YESDoes your pet strain when urinating? YES	NODoes your pet strain when urinating? NO
Does your pet have blood present in its urine?	YESDoes your pet have blood present in its urine? YES	NODoes your pet have blood present in its urine? NO
Is your pet coughing?	YESIs your pet coughing? YES	NOIs your pet coughing? NO
Is your pet sneezing?	YESIs your pet sneezing? YES	NOIs your pet sneezing? NO
Is your pet gagging?	YESIs your pet gagging? YES	NOIs your pet gagging? NO
Has your pet been exposed to any other pets recently?	YESHas your pet been exposed to any other pets recently? YES	NOHas your pet been exposed to any other pets recently? NO
Has your pet had surgery recently?	YESHas your pet had surgery recently? YES	NOHas your pet had surgery recently? NO
Does your pet chew/eat begging, toys, etc?	YESDoes your pet chew/eat begging, toys, etc? YES	NODoes your pet chew/eat begging, toys, etc? NO
Is your pet limping?	YESIs your pet limping? YES	NOIs your pet limping? NO

If your pet is limping, please let us know where:

CPR CODE Consent Agreement

In the event of a medical emergency while my pet is under anesthesia: *

I authorize Northgate Animal Hospital to perform CPR (Resuscitation) on my pet if my pet is suffering respiratory arrest or cardiac arrest. I understand that my pet may not respond initially and then suffer another arrest later. I understand that my pet may die despite life saving efforts being made. I understand that if my pet survives because of CPR, he/she may have additional medical problems as a result of CPR being performed. The estimate for initial CPR is $300 to S500. The estimate for the first 24 to 48 hours of veterinary care after CPR depends partially on pre-existing injury or illness and may be $1000 to $2000: however, costs can greatly exceed this estimate. (FULL CODE STATUS)
I DO NOT want CPR performed on my pet. I understand that if my pet stops breathing and/or his/her heart stops beating that my pet may die unless CPR is performed. I elect to DNR (Do Not Resuscitate) orders placed on my pet's record OR I elect that the veterinary staff stop the initial attempts at CPR that may have been started while I was being informed of the condition of my pet and my options. (DNR CODE STATUS)

***Animals that have been successfully resuscitated are extremely critical and unstable. The likelihood of re-arrest is high and usually occurs within 4 hours of the initial arrest. If resuscitation is successful, there is only about a 20% chance that a pet will stay alive for the first 4 hours after resuscitation. The percentage of long term survival is even lower, and may be as low as 1%, depending upon what caused the arrest. Brain damage is common due to temporary lack of oxygen to the brain, which can result in blindness and/or impaired mental function, leaving a pet with physical and/or mental disabilities. This impairment may last for days, weeks, or years.

I HAVE *

I HAVE READ AND UNDERSTOOD THE INFORMATION ABOVE OR HAD IT EXPLAINED TO MY SATISFACTION.

l am the owner or agent of the owner of the above named pet and hereby authorize the performance of treatment for this pet. I understand that unforeseen conditions may necessitate an extension of the treatment or a different treatment may be recommended and therefore authorize such treatments as necessary in the professional judgment of the veterinarian. I authorize the use of appropriate aesthetics and mediations in the treatment of this pet. I have and will be advised of the nature of the treatment and I understand that while every effort will be made to provide the best care for my pet, results cannot always be guaranteed. I understand that all fees must be paid in full at the time of release unless other arrangements have been made in advance with the veterinarian, medical director or with the practice manager of Northgate Animal Hospital. I have read the above information: I understand and agree to the conditions and policies of Northgate Animal Hospital.

Signature of Owner *

Clear Signature

Date *

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Dental Form

Dental Form

PDF Form

Download Dental Form PDF

NORTHGATE ANIMAL HOSPITAL DENTAL ADMITTING FORM

OWNERS CONSENT FOR ANESTHESIA AND TEETH CLEANING

Drop Off And Pick Up Times

BLOODWORK

LASER SURGERY

CURRENT MEDS

ALLERGIES

EXTRACTIONS

BIOPSY

VACCINATIONS

FLEAS

MICROCHIPPING

ADDITIONAL TREATMENTS

CPR CODE Consent Agreement

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