Dental Release Form Owner* First Last Pet's Name*Date Date Format: MM slash DD slash YYYY Pre-Anesthetic blood work: Untreated periodontal disease often results in infection and/or bacteria filtering into the blood stream, which can have long term and severe effects on the organs. Our doctors recommend that preanesthetic lab work prior to the administration of anesthesia to help detect any underlying problems such as but not limited to anemia, dehydration, diabetes, kidney disease and liver disease.*YES, I would like preanesthetic blood work for ADDITIONAL FEE of $95.00 - $110.00 (Basic or Advanced 7 years & older)NO, I understand pre-anesthetic blood work is recommended for me pet; however I choose to decline at this time.IV Catheter: Placing an IV catheter reduces risk while under anesthesia by allowing us direct access to the circulatory system if needed. This is important because it can be difficult to gain access to a vein in an emergency situation. Giving your pet IV fluid therapy while under anesthesia will help to keep them hydrated as well as keeping their blood pressure stable during the procedure.*YES, I would like an IV Catheter for my pet for an ADDITIONAL FEE OF $27.50NO, I do not wish for my pet to get an IV CatheterExtractions: Dental extractions may be necessary due to advanced dental disease or mobility. Extractions will be done based on the veterinarians best judgment. There will be additional cost ranging from $8.50-$35.00 per tooth depending on severity. More advanced extractions may require oral surgery. Oral surgery ranges from $95.00-$220.00 for up to 30 minutes of additional surgery & anesthesia time. Having necessary extractions done will have a beneficial effect on your pets health.*YES, I authorize LPAH to perform any extractions deemed necessary during today's dental cleaning.NO, I do not wish to have any teeth extracted during today's dental procedure.In the case that I am unable to be reached by phone I authorize LPAH to perform any oral surgery that my pet may need.*YESNOIn the event that extractions are performed, I wish for my pet to be sent home with post operative pain management for an ADDITIONAL FEE OF $20.00*YESNOIf we do not extract any teeth, if deemed necessary by the doctor is it ok to pack the socket with Concil? ADDITIONAL FEE $25.00-&45.00 (PER TOOTH)*YESNOWould you be interested in dental radiographs? (PRICES STARTING AT $25.00)*YESNOAfter carefully reading and filling out this form, I acknowledge full financial responsibility for all procedures and/or tests I have authorized, and I understand that payment in full will be due at the time I pick up my pet. I also understand that any surgical procedure involves a certain amount of risk. By typing your name in the box constitutes a valid electronic signature and with the submission of this form shall act as your legal signature.Signature*Type your name aboveDate* Date Format: MM slash DD slash YYYY Where can we reach you today if needed:Phone #1*Phone #2
