Dental Procedure Consent Form Dental Procedure Consent Form Name * Name Name Name Your Pet's Name * Email * Best Phone Number to Reach You: * Secondary Phone Number: How would you like us to contact you: * Phone call Text message Email Notice of Risk with Anesthesia * The use of anesthesia poses a potential health risk to your pet. To reduce the risks associated with anesthesia, a current pre-anesthetic blood profile (CBC/Chemistry Panel) is highly recommended. A blood profile can help rule our pre-existing conditions that may not be physically evident, but can lead to serious complications. This profile includes tests that check for anemia, infection, diabetes, kidney and liver function as well as any other potential underlying problems. Please choose the option that best fits your pet's needs: Comprehensive (in-house) $434 (CBC+12CARD+UA) Completed within the last 30-45 days I decline the recommended blood work and request that you proceed with the dental procedure. Details on Extractions * Damaged teeth cause pain and disease in the mouth and they require surgical extraction to promote good oral health and proper healing. Pets with significant periodontal disease may need numerous extractions. Every effort will be made to give an accurate estimate, however, at times complete estimates are not possible to determine until the mouth is evaluated under full anesthesia. Please select one of the following: Perform any extractions necessary Call or text me first. If you cannot reach me, your may proceed with any procedure(s) deemed necessary. Do nothing else unless you contact me. I understand that you will recover my pet from anesthesia without doing any additional procedures no matter how minor. I also understand that should I agree to the recommended procedure(s) at a later time it will be a separate anesthetic and dental procedure and will be charged separately. *If you selected for us to proceed with treatment, please list a financial limit in the event further treatment is recommended CPR Authorization * I authorize CPR: I understand there are risks and costs associated with CPR, and I authorize the veterinary team to perform CPR in an attempt to resuscitate my pet in the event of an emergency. Do NOT perform CPR: I understand that by declining CPR, it is very likely that my pet will not survive in the event of cardiopulmonary arrest. In the event your pet experiences an unexpected medical emergency, such as cardiopulmonary arrest while under anethesia, immediate action is critical. Please indicate below where you authorize us to perform Cardiopulmonary Resuscitation (CPR) or if you decline such intervention. Please select one of the following: Signature * signature keyboard Clear Date * Captcha Submit If you are human, leave this field blank.