Feline Dental Consent Form

Client First Name: *

Client Last Name: *

Email Address: *

Street Address:

Apartment, suite, etc:

City:

State/Province:

ZIP / Postal Code:

Home Phone:

Cell Phone:

Pet's Name:

Breed:

Color:

Gender:

DOB/Age:

Procedure(s) to be performed:

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Your pet is in today for dental procedure(s) that require anesthesia; your pets safety is our number one concern. We highly recommend a pre-anesthetic blood profile to be preformed. This will rule out any pre-existing internal problems like (dehydration, anemia, diabetes, infection and/or kidney-liver disease) that may not be evident, physically, but could lead to serious complications and serve as a baseline for future treatment.Yes, perform pre-anesthetic blood testingNo, I decline pre-anesthetic blood testingNo, done prior on…

Dental prophy contest: A thorough dental exam will be performed after your pet has been sedated. Although you may have been provided with an estimate, after your pet has been sedated. Although you may have been provided with an estimate, after your pet has had a complete oral examination, and each tooth has been evaluated, the doctors diagnosis and finding such as (cracked or decaying teeth, lesions, and root exposure) may result in more charges than initially estimated. We highly recommend completing all dental procedures during this visit because dental disease can seriously affect your pets overall health and damage their internal organs.

Please choose one of the options below so we may comply with your wishes.Town & Country Veterinary Services does not need to contact me and may perform any and all necessary procedures and extractions at this time. I accept the costs that may be involved.Town & Country Veterinary Services does not need to contact me and may perform any and all necessary procedures and extractions at this time. I accept the additional costs that may be involved up to the amount listed below.Do not proceed without contacting me of any additional procedures and charges. You can contact me by phone at the number below.

Medications given and when:

Home Again Microchip System (additional cost)YesNoDone prior

If your pet is found to be infested with fleas or ticks they will be treated at your expense.

I am the owner or authorized agent of the owner and am at least 18 years of age. I hereby authorize Town & Country Veterinary Services to perform the procedure(s) noted above and administer anesthetics or other drugs deemed advisable for my pet. I also understand the increased risks of complications by not performing the pre-anesthetic blood profile. I recognize that there is always risks and agree not to hold Town & Country Veterinary Services or any of its staff responsible and it is understood that I assume all risks and financial responsibility. If I fail to pick up my pet in ten days, the animal will become the property of Town & Country Veterinary Service and may disposed of as deemed best. This does not relieve me from any costs or financial responsibility.

Name of authorized person to pick up my pet after surgery if I (owner) is not available:Will not release pet to anyone other than owner or person listed above. Payment is required at time of pick up.

Owner Signature:

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