Dental Auth Form

You can rely on us to maintain your pet’s dental health! To insure the best care possible, please fill out this form completely. Thank You!

Pre-Anesthetic Blood Profile

Your pet is scheduled for a procedure that involves anesthesia. Like you, our greatest concern is the well-being of your pet. Therefore, a Pre-Anesthetic Blood Profile is necessary to screen for kidney or liver problems and check for anemia. This profile may greatly reduce the risk of anesthetic complications as well as identify medical conditions that may require treatment.

Authorization for Extractions

Your pet is scheduled for a dental prophylactic cleaning procedure. An assessment of each tooth is performed as part of the oral examination. Occasionally, teeth are found that should be extracted to improve and maintain the health of the mouth and the overall health of the pet. Severe gum and bone infections are the primary causes for this tooth loss. The decision to extract is made based on standard dental protocols. Please initial next to one statement:

Extended Pain Management

Ongoing Dental Care at Home

After the dental cleaning, which of the following would you like for ongoing dental care at home:

Identification Microchip

Services Required for Admission

Intravenous Fluid Administration is required for all pets under general anesthesia.

I, the undersigned, do hereby certify that I am the owner (or duly authorized agent for the owner) of the animal described above, that I do hereby give Markham Animal Clinic, their agents, and/or representatives full and complete authority to perform the core dental procedure described above and to perform any other procedure that, at their discretion, may be useful to promote the health of my pet. I do hereby release the said doctor, agents, or representatives from any and all liability arising from said procedure on said animal. I understand that all precautions will be taken to insure said patient’s safety and there are risks involved. My signature below makes me solely responsible for the charges listed for the procedures performed on my pet. I accept and agree to the terms of this treatment plan and procedure. I understand that all payments are due in full prior to discharge. The treatment plan provided for this procedure is subject to vary and additional costs may incur depending on the complications and/or unexpected conditions. I understand the veterinarian will discuss these changes, as necessary.

Lifesaving and CPR Procedure

The estimate for said procedure expires in 30 days from the day created.