Owner's Name *

First

Last

Pet's Name *

Best Contact Number *

Email *

Pre-Anesthetic Testing Authorization

Additional Cost

Advances in anesthetic protocols have made anesthesia safer for our patients. While our doctors will perform a physical exam prior to your pet undergoing anesthesia, an exam alone cannot identify all underlying medical conditions, especially if a patient is not displaying any clinical symptoms. Therefore, we strongly recommend pre-anesthetic bloodwork to be performed prior to anesthetic medications being administered to help us identify any abnormalities that could result in an increased risk for your pet or postponing of elective procedures.

Pre-Anesthetic Testing Authorization *

Approve (recommended pre-anesthetic bloodwork testing)
Declined (recommended pre-anesthetic bloodwork testing)

Anti-Nausea Medication

Some pets, like people, can experience nausea and/or vomiting from anesthetic medications. This can increase the risk of a condition called aspiration pneumonia, which can become a serious lung infection. Your pet may also experience uncomfortable, unyielding nausea, and may be unwilling to eat after their procedure or unable to keep food down. We strongly recommend that your pet receive an anti-nausea medication to drastically minimize these risks and unwanted discomfort.

Anti-Nausea Medication *

Approve (pre-anesthetic anti-nausea medication)
Declined (pre-anesthetic anti-nausea medication)

Dental Radiographs

All patients under anesthesia for a Core Dental Procedure will have dental radiographs performed prior to cleaning and polishing of their teeth. Dental radiographs allow our doctors to better evaluate your pets’ teeth. This allows them to assess the health of your pet’s entire tooth and not just the crown. Radiographic findings may result in necessary dental extractions. If any problems are discovered on radiographs, your doctor will go over those findings with you. *

I read and agree (Acknowledgement of the statement above)

Extractions

Extractions are sometimes a part of a Core Dental Procedure. Sometimes teeth may be loose, have fractures, or have major root exposure or disease. In many cases, these teeth require removal due to the potential issues they can cause and pain they can create for your pet. Extractions will be done based on the veterinarian’s best judgement. We can assure you that only necessary teeth will be extracted. The cost of extractions is based on the number of extractions performed and is in addition to the base cost of the Core Dental Procedure. *

I read and agree (Acknowledgement of the statement above)

Pain Medication

Depending on the level of the procedure, a pain injection may be given to your pet post-dental. Every dental patient will be sent home on pain medication if extractions are performed. *

I read and agree (Acknowledgement of the statement above)

Microchip Optional (Additional Cost)

I would like my pet to be microchipped while under anesthesia
I would not like my pet to be microchipped while under anesthesia

Preventative Abdominal Ultrasound Screening (Additional Cost)

This is a voluntary preventative health screening to check for any abnormalities within your pet’s liver, gallbladder, spleen, pancreas, GI tract, kidneys, and urinary bladder that might not show up as abnormalities on blood work. This could include cysts, masses, stones, thickened organ walls, or other slight abnormalities we should be monitoring for changes as your pet ages. Preventative screenings can sometimes lead to incidental findings that allow us to better care for your pet and extend the life of your pet before clinical signs even become present.

I WOULD like my pet to have a preventative abdominal ultrasound performed today.
I WOULD NOT like my pet to have a preventative abdominal ultrasound performed today.

Dental Release Statement

I understand that the doctors and staff at Delta Animal Hospital will use all reasonable precautions against injury, escape, and death of my pet. I understand that anesthesia involves some risk to my pet and give permission to proceed with anesthesia. *

I read and agree

Owner's Signature *

Clear Signature

Date *

Dental Release Form (6 & Under)