Dental Consent Form -

Pet Parent's Name*

First Last

Pet's Name*

Best number to reach you at today*

Secondary phone number*

Last meal time*

Last drink time*

Other medications/concerns

Consent*

I understand and acknowledge that Edmonton West Animal Hospital performs multiple anesthetic procedures each day, and that my pet’s drop off time is not the time that the procedure will be started. I also understand that since extenuating unforeseen circumstances such as emergencies, urgent walk ins, and surgical complications or delays on other procedures can delay the completion of my pet's procedure, no guarantee will be made as to when my pet will be ready, and I will be contacted by hospital staff to schedule a pick up time once the procedure is done.*

PLEASE READ AND INITIAL IN FRONT OF EACH APPLICABLE STATEMENT IN THE SPACE PROVIDED

My pet is being admitted for a dental cleaning and/ or comprehensive oral health assessment under general anesthesia, and, in a few cases, for further treatment such as teeth removal. I understand that with dental disease, problems that are present may not be revealed until a thorough exam after cleaning under general anesthesia is performed. These dental procedures require general anesthesia and I understand and accept that there are always inherent risks, including death of the patient.

The following options can help to reduce the risk associated with anesthesia and maximize patient safety. We highly recommend these measures for every patient having a surgical procedure.

Pre-anesthetic blood screen: the risk of anesthetic complications is higher in animals with health problems. We recommend a pre-anesthetic blood screen for every patient having a surgical procedure. This checks for sub-clinical disease (hidden problems) not apparent on physical examination. On the basis of this blood work we can tailor your pet's anesthetic, pain management and recovery protocols to her/his individual needs. The fee for a pre-anesthetic blood screen is $120.00.

Below, please decide whether you would like to authorize pre-anaesthetic blood screen or if you do don't authorize pre-anaesthetic blood screen and accept the inherent associated risks

Please watch the "Pre Anesthetic Concerns" video (https://vimeo.com/102370458)*

I agree that I have watched the "Pre Anesthetic Concerns" video

Please watch the Dental video (https://vimeo.com/90172872)*

I agree that I have watched the Dental video

Please select one of the following statements below:*

I authorize pre-anaesthetic blood screen
I don't authorize pre-anaesthetic blood screen and accept the inherent associated risks

Intravenous fluids (drip): intravenous (IV) fluids are very important for all procedures that require general anaesthesia. Administration of IV fluids helps your pet recover more quickly from anaesthesia, maintains blood pressure, and increases circulation during anaesthesia. It also allows rapid administration of drugs should an emergency arise and can save vital time in the rare event of an anaesthetic complication. To place an IV catheter and fluids it is necessary to clip or shave hair from the site (forearm or back legs). IV fluids are included with every dental procedure ($60 value).

Below, I will confirm that I understand my pet may have one or more legs shaved in order to place IV fluids

IV Fluids Shaving Consent*

I understand my pet may have one or more legs shaved in order to place IV fluids

Up to 30% of dental pathology occurs below the gum line and cannot be seen on gross examination. Dental radiographs (x-rays) are utilized to assess this potential pathology and our veterinarians highly recommend dental x-rays in order to better evaluate your pet’s oral health. In the majority of cases, radiographs can confirm the necessity for extraction of a tooth that may be loose, damaged or severely diseased. The fee for full mouth dental radiographs is $180.00.

Below, I will confirm whether I authorize the attending doctor to proceed with dental radiographs. or whether I do not authorize any dental radiographs and understand that disease below the gum line involving the tooth roots and all surrounding tissues cannot be fully assessed without radiographs.

Please initial one of the following statements below*

I authorize the attending doctor to proceed with dental radiographs.
I do not authorize any dental radiographs and understand that disease below the gum line involving the tooth roots and all surrounding tissues cannot be fully assessed without radiographs.

In cases where further work of a non-emergency nature (non-life threatening) is required such as teeth removal, selective dental x-rays, etc., every attempt will be made by the doctor to contact the owner to discuss the case. Please be aware that if you decline any needed procedures at this time, or, we are unable to reach you within 5 minutes, your pet would need a second anesthesia at another time in order for those procedures to be performed.

I, the undersigned, owner or responsible party of the admitted patient, hereby authorize the doctors of Edmonton West Animal Hospital & Spay/Neuter Centre (and whomever they may designate as assistants) to administer further work up and treatments as necessary (once the case has been discussed with me, and verbal consent has been obtained) such as teeth removal.

Further, I assume full financial responsibility for all charges incurred to this patient. However, I understand that if efforts to reach me are unsuccessful, and contact cannot be made at the phone numbers provided, no additional work will be performed and may have to be completed at a later date.

Additional non-life threatening work consent*

I understand and am aware that in the event of further non-life threatening work, a Doctor or Staff member will contact me directly for authorization and that declining services will require additional anesthesia for procedures to be performed later

I understand that dental procedures, including simple and surgical tooth removal, can be associated with risks which may include broken tooth roots, bleeding, dry socket, inability of the pet to keep its tongue in the mouth, and damage to surrounding tissues. Rarely, fractures of the bone may occur, necessitating further work. At Edmonton West Animal Hospital, every effort is made to predict and avoid these complications but unforeseen events may occur. I understand these risks and acknowledge that they have been explained to my satisfaction.

Dental Procedure Risk Consent*

I have read the above and fully understand the risks associated with dental procedures.

Additional Procedures

If you would like anything additional done at the time of the dental (e.g. lump removal, vaccination, tear duct flushing, etc), please describe in the box below. Additional cost estimates, where applicable, will be provided to you before these services are carried out, and are at the discretion of the attending veterinarian.

List additional procdures here

Additional Procedure Consent*

I understand that any additional procedures that I authorize (e.g. lump removal, ear plucking, anal gland flushing, tear duct flushing, vaccinations, etc) are at the discretion of the attending veterinarian and his/her clinical judgement. I agree to pay the additional costs associated with these procedures.

Hospitalization Consent*

I understand and accept that if, in the rare event my pet requires overnight hospitalization, there is no overnight staff on duty after the hospital closes, and that my pet will be attended to the following morning.

If you wish to take your pet to a board certified veterinary dental specialist, there is only one in Alberta, and works out of the CARE Centre in Calgary on a referral basis. Do not initial the following blank and inform a staff member if you wish to be referred. In this case, you will not receive a phone call if teeth removal is recommended, and no additional work will be performed. I am aware that Edmonton West Animal Hospital does not employ any board certified veterinary dental specialists, and authorize the general certified veterinarians of this facility to perform the above dental extractions on my pet (once the case has been discussed with me, and verbal consent has been obtained). Below I will confirm whether I would like to be referred to a board certified dentist or whether I do not want to be referred*

I would like to be referred to a board certified dentist
I do not want to be referred

I hereby certify that I have read and fully understand the above authorization for dental and/or surgical treatment. Further, I acknowledge that any surgical/dental or post anesthetic complications may require additional veterinary care or medications which I assume full financial responsibility for. I also certify that no guarantee or assurance has been made regarding the results that may be obtained. I understand that the ultimate success of proposed dental treatment may depend on adequate home care and follow-up and acknowledge my responsibility in this regard, particularly for periodontal disease.

Acknowledgement & Authorization for dental and/or surgical treatment.*

I hereby certify that I have read and fully understand the above authorization for dental and/or surgical treatment. I have no further questions for the veterinarian regarding the current procedure and form. Further, I acknowledge that any surgical/dental or post-anesthetic complications may require additional veterinary care or medications which I assume full financial responsibility for. I also certify that no guarantee or assurance has been made regarding the results that may be obtained. I understand that the ultimate success of proposed dental treatment may depend on adequate follow up home care and acknowledge my responsibility in this regard, particularly for periodontal disease.

I hereby certify that I have read and fully understand the above authorization for dental and/or surgical treatment.*

I certify and authorize.

Signature*

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.

Dental Consent Form

Dental Consent Form

WE HAVE MOVED!

You can find us at:

9962 170 ST NW
Edmonton, AB T5T 5L5

HOURS OF OPERATION

Open 7 days/week 365 days/year!

Temporary COVID-19 Hours:

Monday – Friday 7:30AM – 10PM
Sat, Sun & Holidays: 9AM – 6PM

GET CONNECTED

TOP 3 VETERINARIANS IN EDMONTON!

Awarded every year 2016-2023!

PLEASE CONTACT US

EMAIL: petinfo@vetinedmonton.com
PHONE: (780) 488-0124

Dental Consent Form

WE HAVE MOVED!

You can find us at:

9962 170 ST NW Edmonton, AB T5T 5L5

HOURS OF OPERATION

Open 7 days/week 365 days/year!

Temporary COVID-19 Hours:

Monday – Friday 7:30AM – 10PM Sat, Sun & Holidays: 9AM – 6PM

GET CONNECTED

TOP 3 VETERINARIANS IN EDMONTON!

Awarded every year 2016-2023!

PLEASE CONTACT US

EMAIL: petinfo@vetinedmonton.com PHONE: (780) 488-0124

9962 170 ST NW
Edmonton, AB T5T 5L5

Monday – Friday 7:30AM – 10PM
Sat, Sun & Holidays: 9AM – 6PM

EMAIL: petinfo@vetinedmonton.com
PHONE: (780) 488-0124