Dental Consent Form

Indy Paws Dental Consent Form

Indy Paws Veterinary Hospital Dental Complete Oral Assessment and Treatment Consent

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Pet Owner Information

Client's Name:*

First Name Last Name

Pet's Name*

First Name

Primary Phone Number*

Primary Email*

Estimated Periodontal Disease Level/Procedure (as indicated by estimate)*

Please provide your expectations regarding procedure (additional details below)

Pre-Anesthetic Questions

Please fill out the questions below in as much detail as possible.

Is your pet on any medications?*

Medication name

Amount administered

Time of last dose

If your pet requires medications for anxiety or reactivity for their appointment, please give one dose the night before their appointment and one dose two hours before their appointment.

Please confirm what time you gave your pet’s medications

PM dose given:

AM dose given:

Please confirm which medication(s) you gave your pet:

Gabapentin

Trazadone

Acepromazine

When was your pet's last meal?*

Type of food

Feeding amount

Time of feeding

Pre-Anesthetic Bloodwork and Tests: Procedures requiring anesthesia are always associated with a certain amount of risk, whether the patient is a person or a pet. Like you, we want to minimize that risk as much as possible. General anesthesia has become safer in more recent years as new medications and monitoring equipment becomes available, however, some conditions are not evident on physical exam. To better ensure your pet’s safety during anesthesia, the following pre-anesthetic tests are strongly encouraged:*

Pre-anesthetic Panel, $107, recommended for young and healthy pets (mini-chemistry, complete blood count)

Pre-Anesthetic Panel 2, $149.80, required for geriatric or sick pets (large chemistry with electrolytes, complete blood count)

Decline pre-anesthetic labs. I understand the risks of declining.

Oral Surgery

It is very difficult to perform a complete and thorough dental exam on an awake pet. Therefore, dental estimates are difficult to accurately predict prior to anesthesia. The cost of oral surgery (ie: extractions) is determined by the amount of time and difficulty for the procedures. Once your pet is sedated, each tooth is carefully evaluated through both probing and radiographs to determine the treatment course. Research has shown that severely diseased teeth can cause considerable pain and discomfort and are a source of infection for other organ systems (liver, kidney, lungs, and heart). In order to avoid scheduling repeated anesthetic events for dental treatment, we recommend completing all needed dental procedures in one visit. Oral surgery can be associated with risks. These may include broken tooth roots, infection, dry sockets, oronasal fistulas, and damage to surrounding tissues. Fractures of the bone can also occur, which may require follow-up and treatment with a board-certified dentist. At Indy Paws Veterinary Hospital (IPVH), every effort is made to predict and avoid these complications, but unforeseen events can occur. Post-surgical complications may require additional treatments and expense.

Please let us know how you would like us to proceed once we have evaluated your pet’s teeth:*

Proceed with all procedures, including unforeseen oral surgery as determined by the attending Doctor. I understand that the cost may be higher than provided estimate.

Perform necessary procedures and extractions up to $______. Please call to discuss the case if more work is needed beyond this cost. If I am unable to be reached, only part of the needed treatments will be completed and the procedure may be finished at a later date. This will increase the total cost of the work.

Call me if any additional work, including unforeseen tooth extraction, is needed beyond the initial estimate. I understand that if I cannot be reached, no additional work will be performed and may have to be completed at a later date. This will increase the total cost.

I prefer my pet to be referred to a board certified Veterinary Dental Specialist and do not authorize any oral surgery.

Provide only the requested dental prophy at this time. I understand that this could lead to continued periodontal disease and pain for my pet.

If you selected the option for treatments up to a specific amount above, please indicate the dollar amount that is your maximum for today?

Example $23

Pain Medications

Pain medication is required after oral surgery. The attending veterinarian will assess your pet's anticipated pain level and administer and prescribe appropriate medication. Pain medication can range from $35.00-$100.00 depending on your pet's weight and expected pain level.

Additional/Optional Treatments

In order to ensure safety of our patients and staff, we require up to date vaccinations for all hospitalized patients. If your pet does not have documentation for all vaccinations, they will be administered at the time of their visit. In addition, if any fleas are found, your pet will be treated. By signing below, you indicate your understanding that vaccinations or flea treatments required will be at your expense and may exceed the original provided estimate.

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Pedicure (Nail trim - Courtesy while under anesthesia)

Microchip $77($0 if on puppy/kitten wellness plan)

Anal Gland Expression $29.70

Ear Cleaning $29.70

Heartworm &Tick-Borne Disease Testing ($73.73) or HW/FeLV/FIV Test ($92.31)

Surgical Laser Fee $74.90 (For oral surgery, if indicated. Laser surgery results in less bleeding, decreased pain, reduced risk of infection, and faster recovery after surgery)

I decline all additional treatments.

General Release

I understand that I am leaving my pet in the care of Indy Paws Veterinary Hospital (IPVH) for care and treatment. I have been informed of the procedure my pet is having performed and am aware that the goal at Indy Paws Veterinary Hospital is to practice the highest quality of medical care. Understanding this, I know that IPVH will do everything possible to treat my pet with care and respect while in their care. There are some medical situations that can occur that are beyond the Hospital's control and all possible efforts and resuscitation will be made in case of a medical emergency. I understand that Indy Paws Veterinary Hospital will not be held responsible for an unexpected death of a patient. My pet will be considered abandoned if Indy Paws Veterinary Hospital has not heard from me within 5 days of the expected date of discharge. The hospital is authorized to manage my pet however they deem best if this should occur. I further understand that no guarantee of successful treatment can be made.

In the event that your pet should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of his or her status?*

In case of emergency, best phone number to reach you during the day of the procedure:*

Phone number

Emergency contact information during the day of procedure.*

Name

Phone Number

Policies and Release

I will ensure my pet urinates and/or defecates before drop off. Accidents in the hospital can increase the risk of infection and ensuring empty bowels can reduce this risk. **

I agree

Financial responsibility and obligations

I agree

I certify that I understand this release and furthermore assume full financial responsibility of all charges accrued. I am agreeing to all items listed above and the estimated costs of the procedure as provided. I understand that the initial costs are estimated and are subject to change. If there is anticipation that a change to estimated services is significant (>10%), Indy Paws will make every effort to reach out to discuss prior to proceeding.

Electronic Age Consent

I agree

Checking the “I Agree” box indicates that:
I certify that I am at least 18 years old and legally permitted to provide this information.

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