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DENTAL Surgical Information Form

42-34 Crescent Street, Long Island City, NY 11101
Phone: 718-577-4701

Client Name:

Client Address:

Client Phone #:

Patient Name:

Patient Species:

Patient Breed:

Patient Age:

Patient Sex:

Patient Weight:

Contact Phone #

Primary Contact Person:

Emergency Phone #:

Emergency Contact Person:

For each of the following, select whether the patient needs a refill of their preventative and, if so, specify the quantity (e.g., 1 month, 6 months, etc.)

Heartworm Prevention (Sentinel / Heartgard / for dogs)
For each of the following, select whether the patient needs a refill of their preventative and, if so, specify the quantity (e.g., 1 month, 6 months, etc.)
A
B
Flea/Tick Prevention (Credelio / Bravecto / Seresto Collar for dogs; Bravecto / Seresto for cats)
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A
B
Flea/Tick/Heartworm Prevention (Simparica Trio for dogs; Revolution Plus for cats)
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A
B

PLEASE INITIAL OR ANSWER ALL OF THE FOLLOWING QUESTIONS / STATEMENTS

When was the last time the patient ate?
Is the patient on any medication? List ALL things you are aware that they have ingested in the last week BESIDES the patient’s own food (including but not limited to supplements, human medications, over-the-counter medications, etc.)
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A
B

Preanesthetic blood screening is required to aid us in making sure the patient’s procedure is as safe as possible. This is critical for all patients, not just older pets. If this has not been performed prior to the day of this procedure, I understand that a Preanesthetic Profile will be taken, which will incur additional costs.

Initial:

Signature

I fully understand the risks associated with the surgical procedure identified above, which include, but are not limited to, the following: low heart rate, low respiratory rate, decreased blood pressure, decreased bodily temperature, hemorrhage, and even death.

Initial:

Signature

It's recommended that all pets undergoing a dental procedure also be treated with an Oravet Sealant application to help reduce the need for future dental treatments. The fee for this application is $53.00.

It's recommended that all pets undergoing a dental procedure also be treated with an Oravet Sealant application to help reduce the need for future dental treatments. The fee for this application is $53.00.
A
B

Home care is an important part of your pet's dental health regimen. Weekly applications of Oravet Plaque Prevention Gel, beginning two weeks after your pet's dental procedure, are strongly advised. An eight week supply costs $40.00, and is a convenient and effective means of helping to reduce further dental problems. One box is an eight week supply. How many boxes would you like to take home today?

Home care is an important part of your pet's dental health regimen. Weekly applications of Oravet Plaque Prevention Gel, beginning two weeks after your pet's dental procedure, are strongly advised. An eight week supply costs $40.00, and is a convenient and effective means of helping to reduce further dental problems. One box is an eight week supply. How many boxes would you like to take home today?
A
B
C

Brushing your pet's teeth with a Pet Toothbrush Kit is also recommended as home care, as an aid in preventing the buildup of tartar and plaque.

Brushing your pet's teeth with a Pet Toothbrush Kit is also recommended as home care, as an aid in preventing the buildup of tartar and plaque.
A
B

I am giving permission to extract any teeth as deemed necessary by the attending veterinarian.

Initial:

Signature
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A
B

Initial:

Signature

Would you like to have the patient microchipped today? Fee: $109.25 (This includes implantation of the microchip and the HomeAgain Pet Recovery Registration)

Would you like to have the patient microchipped today? Fee: $109.25 (This includes implantation of the microchip and the HomeAgain Pet Recovery Registration)
A
B
I hereby authorize the performance of the surgical procedure identified above. The nature of the procedure has been described to me to my satisfaction. I acknowledge that no guarantee has been made regarding the results of the procedure, nor could any such guarantee be made ethically or professionally. I understand that I assume financial responsibility for all services rendered, and that payment is due upon hospital discharge of patient.

Initial:

Signature

CPR

In the event that the patient 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 the patient status?
By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion. Please initial your choice below.
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Court Square Animal Hospital takes every precaution to provide the safest sedation and anesthesia for our patients. Even with extreme care and licensed staff, adverse reactions, which are unpredictable, may occur with any sedation/anesthetic procedure. These reactions may include, but are not limited to: cardiac arrest, respiratory arrest and/or even death. I, understand there are always potential risks using sedation/anesthesia.
Initial:
Signature

Signature of Owner or Authorized Agent:

Signature

Date:

I ACKNOWLEDGE THAT NO PERSONAL ITEMS HAVE BEEN LEFT WITH MY PET

Signature