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Your Name

Pet's name

Phone

Email

Would you like us to call or text you with questions or when your pet is ready to go home?

Call
Text

Alternate contact person

Alternate phone number

Please indicate the date of your pet's procedure.

Is your pet having another procedure with the professional dental cleaning?

If you are having any other procedures preformed, please specify.

Have you or your pet been exposed to or tested positive for COVID-19 in the last 2 weeks?

Please explain if you chose yes.

Please explain if you checked any symptoms above.

Please list any medications, supplements, topical treatments your pet will receive or take 24 hours before surgery. Please note if they will be given the night before or morning of surgery.

Please list your pet's heartworm, flea, and tick preventative(s) with date last given or applied.

What do you feed your pet, how much, and how often?

Authorizations

Authorizations

I am aware that dental procedures for pets require the use of anesthesia in order to 1) maximize visualization of the gums, teeth, and oral cavity, 2) minimize movement and discomfort, and 3) provide for the safety of the veterinarian and hospital staff.

I understand.

I have been informed that my pet is in need of preventative or therapeutic dental care and consent to the appropriate procedures described to me by the veterinarians of McKinney Animal Hospital. These procedures include but are not limited to: 1) dental prophylaxis (routine teeth cleaning and polishing), 2) dental radiographs, 3) extractions, 4) antibiotic gel implants, 5) gingival flap surgery to close gaps left by extractions, 6) root canal procedures, 7) root planing, 8) fillings for cavities, and/or 9) orthodontic work.

I understand.

I understand that an estimate of the fees for the above dental care will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered. I have been informed that a dental examination/cleaning often reveal abnormally loose, fractured or otherwise damaged teeth that should be extracted to prevent oral discomfort and ongoing infection of surrounding bone.

I understand.

note2

Every effort will be made to contact you to gain consent to perform extractions if needed. Please be available at the number listed above in order to give permission for additional dental procedures if needed.

In the instance that McKinney Animal Hospital is not able to reach me at the number provided below my preference regarding extractions is (please check one option below):

1. Perform any necessary extractions at this time. I understand that my pet will be started on antibiotics and pain medications postoperatively. I agree to assume financial responsibility for these additional charges.
2. Call me after the dental cleaning and radiographs to provide an estimate of any additional procedures. You can reach me at the number listed above. I understand that if I cannot be contacted at this number, necessary extractions will be performed and my pet will be started on postoperative antibiotics and pain medications. I agree to assume financial responsibility for these additional charges.
3. Call me after the dental cleaning and radiographs to provide an estimate of any additional procedures. Do not proceed without authorization. I can be reached at the number listed below. I understand that if I cannot be contacted at this number no extractions will be performed and I assume all responsibility for any complications this decision may cause for my pet. I also understand that if I decide to have these services performed at a later time, I will need to schedule a future appointment with separate and some recurrent charges (anesthesia, IV catheter, IV fluids, etc).

Please provide the maximum charge you are consenting to, if you chose one of the top 2 instances.

note3

Complications of dental extractions

Complications during dental extractions are not common but as with any surgical procedure, they are always a possibility. Although we take every precaution to prevent them, they can still occur. Some potential complications of dental extractions are:

Fracture and retention of root of a tooth during extraction which may require follow-up removal by veterinary dental specialist.
Displacement of root of tooth during extraction into sinus cavities, nasal passage, or mandibular medullary canal which may require follow-up removal by veterinary dental specialist or another veterinary surgeon.
Inability to complete extraction of a root due to root being ankylosed (tightly adhered to bone surrounding the root) to alveolar bone. If it is warranted that root be removed, referral to veterinary dental specialist may be required.
Fracture of mandible (jaw) during attempt at extraction. This is a rare occurrence but is primarily seen in pets with diseased mandibular bone associated with dental disease or with small animals with thin/weaker mandibular bone integrity.
Potential chronic oral/nasal fistula at site of upper canine tooth extraction which require multiple surgeries to repair or referral to veterinary dental specialist.
Due to the number of extractions some pets require during the dental procedure and the length of time pet has been under anesthesia, some extractions or procedures may be staged or postponed and performed at a follow-up visit or pet may be referred to a veterinary dental specialist for the necessary extractions.

I understand the risk and that potential complications that may occur with dental extractions.

I understand and accept the risk.

I understand that to help avoid or detect problems which may prove that anesthesia would be detrimental for my pet, my pet will be screened by means of a Pre-Anesthetic blood panel if it has not been performed within the last 30 days.

I accept.

I certify that I am the owner of the above-named animal or am responsible for it and have authority to execute this consent. I hereby authorize the performance of the above procedure(s) or treatments by McKinney Animal Hospital doctors and staff. The nature of the procedure(s) has been explained to me and no guarantee has been made as to the results or cure. I understand that there is a risk involved with the administration of anesthesia, up to and including death. I have been encouraged to discuss any concerns I have about the risks involved with the attending veterinarian before the procedures are initiated. Should life-saving emergency care be required and the attending veterinarian is unable to reach me, the staff has my permission to provide such treatment and I agree to pay for such care. I agree to indemnify and hold you harmless from and against any and all liability arising out of the performance of the procedures referred to above and below.

I accept.

I understand that an intravenous (IV) catheter will be placed to allow for administration of fluids and/or medications during the anesthetic/surgical/dental procedure. (A small area of hair will be shaved in order to place the catheter).

I accept.

I understand that pain relief medication will be administered to my pet to minimize postoperative pain and discomfort. Pain medications are administered in injection form prior to most surgical procedures. In some instances a post operative pain or anti-inflammatory injection may be given to help minimize pain and/or inflammation. Post operative pain medication in tablet, pill, or liquid form will be dispensed to continue at home.

I accept

I have had the opportunity to ask questions and those questions have been answered to may satisfaction.

I accept.

I have read and accept the above stated terms.

I accept.

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