Dental Release Form

Dental Release
Name
Name
First
Last
I hereby consent and authorize you as the doctor and staff of Sahara Pines Animal Hospital to receive, prescribe for, treat and operate upon my pet
I, the owner or agent for the above pet, realize that no guarantee or warranty can professionally or ethically be made regarding results or cure. I understand that with the use of any anesthetic agent, an element of risk is involved and will NOT hold Sahara Pines Animal Hospital or its agents responsible or liable under any circumstances. I further request and authorize the doctors of Sahara Pines Animal Hospital to do what they deem advisable or necessary should any unforeseen conditions arise. Possible alternative methods of treatment, risks involved and possible complications have been fully explained and understood by me.

Dental Procedures include (check each to acknowledge)

IV CATHETER & FLUIDS
IV FLUIDS help support the heart and blood pressure during any anesthetic procedure. In an emergency, the IV CATHETER also provides rapid intravenous access to support the body with medications.
COMFORT MANAGEMENT PACKAGE
As a smooth and comfortable recovery helps to ensure better healing, a Pain Relief Injection preceding the dental prophy will be performed.

Available Blood Tests

At Sahara Pines Animal Hospital we are constantly striving to provide your pet with the very best care utilizing the latest in medical technology. While every animal receives a full physical examination before anesthesia, there are certain conditions of the liver, kidneys and blood that cannot be detected unless BLOOD TESTING is performed. These tests are performed safely and accurately in-house before induction of anesthesia.
Pre-operative Panel (selected chemistries + PCV)
Additional Cost: $114.70
Require for any pet undergoing anesthesia.
Full Blood Panel (full chemistries + CBC)
Additional Cost: $204.63
Mandatory for any pet over 7 years.

EKG Screening

An EKG screening can help detect underlying HEART DISEASE that cannot be detected during a routine physical examination.
Additional Cost: $98.01
Highly recommended for any pet, especially for those over 7 years of age. (May be required in certain cases where there is suspected or known cardiac disease.)

Additional Recommended Options

Fluoride Treatment
Additional Cost: $12.46
Fluoride is important in producing HEALTHY STRONG TEETH. While most important in young growing animals, all pets can benefit from this treatment. Fluoride is available for all pets undergoing anesthesia with tarter free teeth. Strongly recommended after dental cleanings!
Full Mouth Dental X-Rays
Additional Cost: $142.84
Dental radiographs are the only way to know the TRUE HEALTH AND STABILITY of your pet’s teeth. Full mouth dental x-rays are performed, along with a visual exam, to help detect any abnormalities with in your pet’s mouth while they are under anesthesia. This is especially important in toy breeds and cats.

Release For Extractions Or Additional Procedures

Every dental prophy performed at our hospital includes an ultrasonic scaling to remove plaque and tartar and polishing to smooth and strengthen the tooth. Factors that may limit our ability to detect every dental problem your pet may have include:
  • Lack of patient cooperation can impair visualization, especially of the back teeth
  • Many periodontal problems can be detected only by probing under the gum with an instrument
  • Dental tartar can hide underlying cavities or fractures.
If further problems are detected while your pet is under anesthesia, please select one of the following options
If for some reason, I am unavailable when you call, please (select one)

Authorization and Release

I hereby authorize the doctors and staff of Sahara Pines Animal Hospital to perform the dental procedures as outlined above. I assume full responsibility for the payments due when services are rendered.