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Dental Procedure Form - West Hills Animal Hospital

Name

Pet's Name

Address

Breed

Age

Weight

Sex

Color

Primary Contact Name (change if necessary)

Primary Contact Phone

Emergency Contact Name

Emergency Contact Phone

When was the last time your pet ate?

Is your pet on any medication?

Is your pet on any medication?
A
B

Do you need any of the following? Please select:

Do you need any of the following? Please select:
Preanesthetic blood screening is required to aid us in making sure your pet'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 then a Preanesthetic Profile will be taken.
It is 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 $37.00.
Oravet Sealant
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 $35.00, and is a convenient and effective means of helping to reduce further dental problems. One box is an eight week supply.

How many boxes of Oravet Plaque Prevention Gel would you like to take home today?

How many boxes of Oravet Plaque Prevention Gel would you like to take home today?
A
B
Purina Dental Chews, as well as brushing your pet's teeth with a Pet Toothbrush Kit, are also recommended as home care, as an aid in preventing the buildup of tartar and plaque.

I would like Purina Dental Chews

I would like Purina Dental Chews
A
B

I would like a Pet Toothbrush Kit

I would like a Pet Toothbrush Kit
A
B

Dental Radiographs

I am giving permission to have dental radiographs and the extraction of any teeth as deemed necessary by the attending veterinarian.

Initials

Authorization

I understand that it is required that my pet is be up to date on any vaccinations and lab work deemed necessary by the doctors of West Hills Animal Hospital & Emergency Center, including, for dogs, leptospirosis vaccines and Canine Influenza vaccine. Any fees involved in satisfying this requirement will be included on my final invoice and are my responsibility.
I hereby authorize the performance of the above procedure. The nature of such service has been described to me to my satisfaction and I realize that no guarantee or warranty can ethically or professionally be made regarding the results or cure.

Signature of Owner or Authorized Agent

Signature

Date