Dental Agreement

Dental Procedure Agreement Form

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Owner Name *

Best Contact Number for Today *

Pet Name *

Email *

Procedure Agreement
As the owner/agent of this pet, I hereby grant my consent and authorize the veterinarian and staff at Evergreen Animal Hospital to treat, anesthetize, and/or operate upon my pet. I understand that during the performance of this procedure, unforeseen conditions may occur that require extension or variance of the planned procedure(s). I understand that the nature of the procedure(s) and risks involved; I realize the results cannot be guaranteed. I am also aware that unforeseen events resulting from the procedure(s) will not relieve me from any obligation to all costs incurred regarding the animal. Evergreen Animal Hospital will perform the procedure/surgery to the best of their ability; the hospital makes no guarantee or warranty regarding the results and I will not hold them liable.

Pre-Anesthetic Blood Panel
Anytime an animal goes under anesthetic, there is a risk for problems to arise due to pre-existing conditions not evident from a physical exam alone. To help reduce the risk of such problems, we recommend a pre-anesthetic blood panel for your pet. While this panel will not guarantee the absence of problems while under anesthetic, it may allow for the detection of factors that may lead to such problems. The pre-anesthetic blood test evaluates kidney and liver function which are essential organs in the metabolism and recovery of anesthetic. It also checks for diabetes.

The blood test is an additional $86.60 *

Accept Decline

Dental Procedure Protocol
Your pet has been scheduled for a dental procedure to treat and prevent periodontal disease. General anesthesia is required to perform these procedures. An oral examination will occur and then we will examine your pet’s teeth and gum tissue using a dental probe to determine if any further treatment is needed, such as extractions. Extractions of diseased or damaged teeth may be necessary to prevent any further advancement of periodontal disease. Then your pet’s teeth will be scaled, polished, and rinsed. Please indicate your pet’s extraction protocol below.

Extraction Authorization *

YES, perform any necessary extractions at the discretion of the veterinarian, I understand that I am responsible for any additional fees resulting from the extraction procedure. NO, DO NOT perform any extractions or additional procedures beyond a basic dental cleaning. I prefer to be called prior to any extractions. I understand that my pet will be under anesthesia at this time and if I am unable to be reached within 5 MINUTES of the initial call the extractions will not be performed. This will result in having to schedule a separate time for extractions and I will be responsible for the costs associated with the additional procedure. I prefer to be referred to a dental specialist if extractions or procedures are needed beyond a basic dental cleaning.

Post-Operative Pain Management
Every patient receives a painkiller injection during surgery when the veterinarian deems it necessary. If you would like us to send home follow-up pain medication, please confirm that decision here.

Would you like your pet to go home with follow up pain management? *

YES, I want my pet to go home with follow up pain medication NO, I do not want my pet to go home with follow up pain medication

Additional Services
A complimentary nail trim and ear flush will be performed while your pet is with us, if you'd like any additional services please select them below.

Choose Any *

Anal Gland Expression Growth Removal Microchip Other (Please describe)

OTHER *

Vaccinations

If your pet is overdue on any vaccinations or has any due soon, would you like to update them today? *

Yes No

We will contact you as soon as your pet’s procedure is complete. A technician will explain all pertinent information regarding the procedure at at-home care. Payment in full is required at the time of pickup.

By signing below, I agree I have read and understand the terms of the above document. I give Evergreen Animal Hospital permission to perform the procedures as described above. *

Owner E-Signature *

Please enter any additional information/requests for Dr. Burton below *

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