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:

I authorize the veterinarian to extract any teeth that cannot be saved. This decision is based on the assessment of the tooth and the gum and bone disease involved. *

I wish to be contacted before any extractions of teeth. I understand that if I cannot be reached, the diseased teeth will not be extracted. *

Extended Pain Management

If there are extractions your pet will receive an injection for pain relief. We require, for the comfort and well-being of your pet, that pain management be continued for three to five days after extractions or other oral surgery. We will send home pain medication. There will be an additional charge for this 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:

Pet Toothbrush/Toothpaste -daily use
Nothing. I’ll have my pet’s teeth professionally cleaned yearly or as needed.
Oravet Dental Chews-daily use
Chlorhexidine Oral Spray-daily use

Identification Microchip

A small microchip placed in your pet will help reunite you with your pet if lost or stolen. The cost of the microchip and registration to you is $

Please initial next to one statement.

YES, I want a Home Again Identification Microchip placed in my pet while under anesthesia.
NO, I do not want a Home Again Identification Microchip placed in my pet today.
My pet already has a Identification Microchip.

Services Required for Admission

Vaccinations MUST be current for admission to Markham Animal Clinic. If your pet is out of date, they will be given the following:

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

Option 1: I DO AUTHORIZE Markham Animal Clinic to perform lifesaving treatment, including the administration of medication, oxygen, ventilation, chest compressions and other emergency measures the veterinarian deems medically appropriate. The veterinarian will make attempts to contact me in the event of an emergency. This will be at an additional cost to the estimate provided at a minimum of $200.00

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

Option 2: I DO NOT AUTHORIZE Markham Animal Clinic to perform any lifesaving procedures on my pet. The veterinarian will make attempts to minimize pain and suffering as they try to contact me and guide me in the management of my pet’s care

Signature of Owner

Clear Signature

Date

I can be reached at the following number:

I prefer a text on the following number:

New Clients: Receive $25 off your first visit!

Dental Auth Form

Pre-Anesthetic Blood Profile

Authorization for Extractions

Extended Pain Management

Ongoing Dental Care at Home

Identification Microchip

Services Required for Admission

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

Lifesaving and CPR Procedure

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