400037 - Marine View Veterinary Hospital

Name

First NameLast Name

Pet's Name

Email

example@example.com

Primary Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Primary Phone Type

Alternate Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Alternate Phone Type

Date of Procedure

MonthDayYear

Reason for Today's Visit

When was your pet last fed?

Does your pet have any food allergies or dietary restrictions?

Please list food allergies or dietary restrictions.

Does your pet take any medications?

List all medications your pet takes. Include drug name, strength, and quantity.

When was your pet was last given medication?

As with any medical procedure, anesthesia/surgery is not without risks. Any patient may experience complications, including but not limited to incisional infection, incisional dehiscence, and in rare circumstances even death.

I understand that unforeseen circumstances may necessitate altering care. I assume responsibility for any additional expenses incurred due to this including but not limited to recommended recheck exams, medications, bandaging, radiographs, and additional surgery.

Pre-Anesthetic bloodwork, if not already performed, is required for all patients undergoing anesthesia/sedation to help evaluate organ function prior to the procedure. You will be contacted if concerns arise that would alter the recommended treatment plan prior to the procedure.

I agree to comply with the aftercare instructions and understand failure to do so can increase the risk of post-operative complications.

Life Sustaining Efforts Directive: In the unlikely event of cardiac or respiratory arrest it is our policy to always attempt resuscitation (CPR), unless "Do Not Resuscitate" (DNR) is selected. You will be responsible for the additional costs associated with CPR. Please select CPR or DNR.

Would you like to discuss any concerns with the doctor before your pet's procedure today?

If your pet is having a dental procedure today, it is possible that he or she may need oral surgery (extractions) and/or special medical procedures. The cost of this can vary widely depending on the type and extent of the needed work. An accurate estimate can only be generated by the doctor after the radiographs and oral exam is complete and can be provided at your request before proceeding.

Would you like a doctor to call you should your pet need extractions today?

Sanos is a dental sealant for dogs that can be applied after a professional dental cleaning to aid in the prevention of periodontal disease for 6 months. It is applied in the gingival sulcus and acts as an invisible barrier to help prevent bacteria from getting under the gumline where it causes periodontal disease. The cost of the product and application is $100.88

For dogs undergoing dental prophylaxis, would you like to have SANOS applied?

Printed Name for E-Signature

First NameLast Name

Date

MonthDayYear

Are You A Robot?

Anesthesia Consent

Client Information

Procedure Information

Anesthesia/Surgery Consent:

Dental Procedures:

Sanos: