Dental Anesthesia Admitting Form Patient: Procedure Dental Cleaning & Oral Exam, Other Other Procedure: The doctors and staff at Lunsford Veterinary Care Center are committed to providing our patients with the safest and most advanced healthcare that we can offer. All anesthesia and surgery involve some potential risks and complications for your pet. Your pet will receive a preanesthetic risk assessment to check their vitals and rule out any obvious external physical reasons that would lead to any unnecessary risks from anesthesia and/or surgery at this time. There are limits, however, to the information that outward physical symptoms can warn us about. For this reason, we will perform Pre-Surgical Bloodwork, allowing a more thorough evaluation of your pet’s health and can pick up problems that might otherwise have been missed like anemia, diabetes, or early kidney disease. We will also place an I.V. catheter and administer I.V. fluids in many cases to further safeguard your pet. Additional Optional Services Nail Trim $16.50 +Tax Ear Cleaning $18.00 Dental Extractions Depending on the condition of ’s teeth, it may be necessary to remove unhealthy teeth. It is often difficult to know the health of individual teeth until we are able evaluate them while is under anesthesia. Yes, I authorize any extractions at the veterinarian’s discretion up to: $50 $100 $150 $200 I will be available at the phone number below for the doctor’s call to approve any extractions over this amount. I understand if the doctor is unable to reach me, no additional teeth will be removed, and it may be necessary to bring my pet for another anesthetic procedure to complete today’s treatment. No, I do not authorize the veterinarian to perform any extractions without my express consent. I will make myself available at the phone number given below for the doctor’s call. I understand if the doctor is unable to reach me, no teeth will be removed, and it may be necessary to bring my pet for another anesthetic procedure in order to complete today’s treatment. Pain Management In the event any extractions were performed today, a pain management package will be provided to ensure the comfort of your pet. ($40) Microchipping We offer permanent identification for your pet through HomeAgain microchipping. This tiny microchip can be placed under the skin between the shoulder blades while your pet is asleep. Yes, I would like a HomeAgain Microchip placed for my pet. I understand there will be an additional fee of $35 for microchip placement and $21.99 for the initial membership and registration. No, I do not authorize my pet to be microchipped today. We are happy to provide you with more information about microchipping! This is a service that does not require anesthesia, should you choose to do this in the future. Make My Pet Famous! I authorize LVCC to use my pet’s photograph and name for Facebook and other promotional publications. I do not authorize LVCC to use my pet’s photograph and name for Facebook and other promotional publications. You are to use all reasonable precautions against injury, escape, or death of my pet. I understand that anesthesia and surgery always involve some risk and agree to hold you harmless, in the absence of negligence in connection with these procedures. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. In the event, a complication arises and I cannot be immediately contacted at the below-listed phone number, you are directed to make the decision and deem it best for my pet. I agree to pay for services rendered. I have read the foregoing, understand what it says and agree. Name First Name Last Name Email Phone (###) ### #### Date MM DD YYYY Preferred method of contact: Phone Call Text Message Thank you! We will email you if we have any questions.
