Date *

Owner's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pet's Name *

Preferred Phone *

Secondary Phone

Email *

Please be available to us today while your pet is here. How do you prefer that we contact you, phone or text? *

Phone
Text

YOUR PET HAS BEEN SCHEDULED FOR A COMPREHENSIVE ORAL EXAM AND TREATMENT.

Sometimes the doctor will find teeth that need to be extracted. This may involve extra expenses, such as increased anesthetic time, local anesthetic blocks, pain control, antibiotics, and the cost of extracting the tooth or teeth. It is very important that the doctor understands your expectations regarding dental extractions.

Please be aware that choosing the second option may necessitate your pet undergoing the extractions at a later date, and all applicable fees will be charged. There will be no discount on anesthesia or other associated costs.

In order to minimize the length of time your pet is under anesthesia; we will limit the time that we attempt to contact you to 5 minutes. It's important that you have your phone accessible to you today so that we can reach you if necessary. *

I authorize the doctor to perform any needed extractions.
I do not want any teeth extracted without my permission. I understand that if I can't be contacted, no extractions will be done.

PREOPERATIVE BLOOD PANEL

Like you, our greatest concern is the health and well-being of your pet. Because your pet cannot describe symptoms to let us know what might be wrong, we run blood tests to give us the answers we need, especially before surgery. By testing blood chemistries, we can evaluate the status of your pet’s major organs. The latest in technology has enabled us to run blood chemistries quickly and accurately before anesthetic induction. Senior pets (those 8 and over) are required to have this test done prior to any anesthetic procedure.

The Prep Profile II provides six chemistry values, which evaluate the liver, kidneys, and detect anemia and diabetes. Includes ALP, ALT, BUN, CREATININE, GLUCOSE, TOTAL PROTEIN, PACKED CELL VOLUME. *

My pet recently had the appropriate blood chemistries run.
Yes, I want the Prep Profile II blood tests run.
No, I do not want my pet to have the Prep Profile II blood tests run.

IV FLUIDS

We require fluid therapy for any patient undergoing a general anesthesia for dental procedures. Fluid therapy is an important element of anesthetic patient management because it helps: *

Maintain hydration
Maintain blood pressure
Provide ready access to a vein for medication

Until your pet learns to use the phone, a microchip will help him find his way home! *

Yes, I would like my pet to be protected with a microchip.
No, I do not want my pet to have a microchip today.
My pet already has a microchip.

Please list any other procedures that you would like to have done today: *

Multiple Choice *

I understand that during the performance of the foregoing procedure(s) or operations(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or operation(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) or operation(s) if necessary and desirable in the exercise of the veterinarian’s professional judgment.

Multiple choice *

I also authorize the use of appropriate anesthetics and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. The nature of such service has been described to me to my satisfaction, and I realize that neither guarantee nor warranty can ethically or professionally be made regarding the results or cure.

Multiple Choice *

I understand that I assume financial responsibility for all services rendered and that payment is due on the date of the surgery.

Multiple Choice *

I hereby authorize the performance of the oral exam (which may include dental radiographs), ultrasonic cleaning, and extractions (as authorized above).

Chicago Cat Clinic

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