DENTAL TREATMENT CONSENT FORM

Date*

OWNER'S FULL NAME*

PET'S NAME*

SPECIES*

Dog
Cat
Ferret
Other

VACCINATIONS must be current to stay in the hospital. If your pet has been vaccinated elsewhere, please either bring a copy of the records (or receipt) or upload a copy to us prior to your pet's visit.*

I verify that my pet has had a Rabies vaccination and Upper Respiratory/Distemper vaccination within the last 1-3 years

Yes
My pet was vaccinated elsewhere
No. Please vaccinate my pet today

Proof of vaccinations from another location

Max. file size: 200 MB.

EXTERNAL PARASITES: Pets found to have fleas or ticks upon presentation will be treated and charged accordingly ($15.00 for pets under 25#, $25.00 for pets over 25#) PRE-ANESTHETIC BLOODWORK Pre-Surgical Lab Testing appropriate to your pet's age and health status has been performed or will be performed prior to giving any medications.

Feline Leukemia/ Feline Immunosuppressive Virus Testing is recommended annually for roaming outdoor cats, sick cats, or cats with gingivitis/ stomatitis.

Yes, Please ($43.00)
No, thank you

ANESTHESIA: I authorize the use of appropriate anesthetics and other medications. I understand that during this procedure(s), unforeseen conditions may be revealed that necessitate an extension of the same or different procedure(s) than set forth above. I also understand that, despite pre-surgical exams and diagnostics, unforseen conditions may exist that may cause unexpected anesthetic complications. I authorize the Doctors and Staff to do everything within their power to prevent anesthetic complications.

RESUSCITATIVE DIRECTIVE*

In the unlikely event of Cardiac Arrest, I authorize the following:

CPR (If I am not reachable within 15 minutes, I understand that CPR efforts will be discontinued if spontaneous breathing has not been recovered. I agree to pay all costs incurred in resuscitation.
Do Not Resuscitate and please assist humane euthanasia.

EXTRACTIONS*

In the event that I can not be contacted during my pet's procedure, I authorize the Doctor to perform extractions that are deemed necessary and will only be performed when the Doctor determines that the tooth can not be saved.

I agree to extractions and the costs incurred.
I do NOT authorize dental extractions until I am contacted for permission. I understand that, if I am not available for authorization, extractions will not be performed and my pet will be awakened from anesthesia.

ORAVET, PLAQUE BARRIER SEALANT*

Oravet can be applied after the teeth are cleaned to reduce the build-up of new plaque. This is especially helpful for small breeds and dogs prone to rapid tartar accumulation. Follow up home care, once a week, is important to continue the benefit of this treatment

Yes, Please ($53.00)
No, thank you

OTHER SERVICES

I would also like the following procedures performed

Toenail Trim ($13.00)
Anal Sac Expression ($26.00)
Microchip/ Registration ($57.60)
Bath (40# and under: $25.00, Over 40.1# and up: $35.00))
Brush out ($5.00 to $25.00)

CONTACT INFORMATION*

It is CRITICAL that we have contact information so that you can be reached throughout the day in case of Emergency or the Doctor needing to discuss your pet's condition. Preferred Method of Communication Today:

Phone call
Text
Email

Phone

Alternate Phone

Text Number

Email

Anything Else? Notes to your Cimarron Team?

$ TREATMENT PLAN*

I have signed a $Treatment Plan for the cost of the procedures indicated in this Document
I have not signed a $Treamtment Plan, please contact me.

By Typing my Name Below*

I authorize a Dental Treatment (General anesthesia/ Dental Radiographs/ Dental Cleaning) to be performed on my pet in my absence. I further authorize any other procedures that I have indicated in this document. I have been advised as to the nature of the procedure(s) and the risks involved. I realize that results cannot be guaranteed. I agree to pay for all services rendered at the time of my pet's discharge regardless of outcome.

First Last

Date Signed*

Call 520.886.1125

180 N. Harrison Road

Tucson, AZ 85748 Map It

HOURS

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Sat 9:00am-4:00pm

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