Lakeland Dental Consent Form

1
Patient name
Client name
Phone number
Email
Medications patient is currently taking
Current conditions or concerns
Please Select
Please Select
Yes
Declined
Preoperative blood work completed
2
Date
Date
Year
Month
Day
3
Antibiotics: Antibiotics are administered during each procedure to minimize the risk of infection. For post-operative care,an appropriate antibiotic will be sent home with your pet in the form easiest for you to administer. (cost varies)
Pill
Liquid
Convenia ($4.00/lb)
Clindoral
4
Pain medication: Pain medication is administered to each patient as part of our sedation protocol. To follow with the same standard of care, pain medication will be sent home for your pet in the form easiest to administer. (cost varies)
Pill
Transdermal
5
Flea medication: Fleas are external parasites that can carry many pathogens and present a health risk to not only our pets, but the entire household. To protect us, you, and other patients in the hospital, any animal admitted for surgery must be current on flea preventative or one will be applied. (cost varies)
Please Select
Please Select
Current on preventative
Product to be applied when admitted
6
Product used
Date of application
7
Nerve block: Nerve blocks are used to numb the nerves in the mouth, relieving pain. If an extraction is necessary, this will automatically be administered to your pet. ($15.00)
8
IV placement: Intravenous catheter placement allows for IV fluid administration during and after surgery to maintainoptimal blood pressure, recovery from sedation, and allows for immediate administration of IV medications should ananesthetic complication arise. ($80.00)
Yes
No
9
Anti-inflammatory medication: These medications reduce swelling and soreness, working in conjunction with pain medication to relieve mild to moderate pain and ensure your pet is comfortable during recovery. (cost varies)
Please Select
Please Select
Yes
No
10
If yes please specify
Pill
Liquid
Transdermal
11
Periodontal laser treatment: Our class IV laser works on a cellular level to reduce inflammation and help gums heal quicker after the dental procedure. ($35.00)
Yes
No
12
Sanos dental sealant: Gingival dental sealant for dogs and cats that seal the sub gingival gum line against the formation of plaque. Clinically proven to last for 6 months without any at-home applications. ($80.00)
Yes
No
13
Digatherm exam: Using digital thermal imaging, this non-invasive technique can reveal sources of pain and inflammation within and surrounding bones, joints, and tissue. ($25.00)
Yes
No
14
Fecal exam: Fecal exams can detect parasites even when no symptoms are present, and are an essential component of preventive medicine. ($24.00 - $30.00)
Yes
No
15
Vaccinations: While an up-to-date rabies vaccination is required prior to surgery, we highly recommend each patient be current on all vaccinations. We can update vaccinations while your pet is here for their procedure, but please note that an examination is required if one has not been performed in the last 30 days. (exam cost $50.00, vaccine cost varies)
Please Select
Please Select
BORDETELLA
DHLPP
INFLUENZA
LYME
RABIES 1 YR / 3YR
Canine
Please Select
Please Select
FVRCP
FeLV
INTRANASAL UR
RABIES 1YR / 3YR
Feline
Due for
16
I, the owner or agent for the owner, hereby consent and authorize the procedures, services, and items listed above.

I understand during the performance of the foregoing procedure, unforeseen conditions may necessitate an extension of the procedure, or different procedure(s) than those set forth above. Therefore, I consent to the performance of such procedures as are necessary in the exercise of the veterinarian’s professional judgement. I authorize the use of appropriate anesthetics and other medications. I have been advised as to the nature of the procedure(s) and the risks involved. I realize that results cannot be guaranteed.
17
If you cannot be reached immediately when a decision must be made for the care of your pet would you like us to proceedwith care of your pet at the discretion of the attending doctor?
Yes
No
18
I HAVE READ AND UNDERSTAND THIS AUTHORIZATION AND CONSENT.
19
Signature
Clear
20
Date
Date
Year
Month
Day
Should be Empty: