Anesthesia and Dental Procedure Consent Form -

Client Name*
First Last
Please list any medications or supplements your animal may have had within the last 7 days and when the last dose was given
A basic dental cleaning includes the following:
- General anesthesia, monitoring and technician care and recovery.
- Oral examination by Veterinarian
- Ultrasonic scaling above and below the gum line, polish the teeth
- Probing for gingival pockets and abscesses
- Fluoride treatment of all teeth depending on patient needs
- Complete dental charting
Costs for a basic dental vary according to length of procedure and size/weight or the patient. Extractions, tooth fracture repair and other corrective procedures will have additional costs.

A $250.00 deposit is required on the day of the patient's scheduled dental.
Pre-anesthetic Lab Work
$120 (Includes Blood Draw Fee)
Lab tests recommended better evaluate your pet internally and establish a baseline for future reference.
Additional Procedures Requested
- Complete Blood Cell Count/Pre-anesthetic Screen*
*REQUIRED FOR DOGS OVER 9 YEARS, GIANT DOG BREEDS OVER 5 YEAR AND CATS OVER 12 YEARS
Accept/Decline Service*
- I accept pre-anesthetic Lab Work
- I decline pre-anesthetic Lab Work
Intravenous Catheter and Fluids
$34.00-$60.00
REQUIRED FOR DOGS OVER 9 YEARS, GIANT BREEDS OVER 5 YEARS AND CATS OVER 12 YEARS.
REQUIRED FOR EXTENDED AND ADVANCED PROCEDURES
Accept/Decline Service*
- I accept Intravenous Catheter and Fluids
- I decline Intravenous Catheter and Fluids
Pre-anesthetic ECG Screen
$55.00
Assess cardiac rhythm for irregularities that may complicate anesthesia.
Accept/Decline Service*
- I accept Pre-anesthetic ECG Screen
- I decline Pre-anesthetic ECG Screen
Possible Additional Costs
After an oral examination, we may recommend dental radiographs, tooth fracture repair, periodontal treatments and/or extractions. Cost for simple extractions are $5-$30 per tooth but can range as high as $50 for more involved extractions. Many pets require no additional work but further costs can range as high as $1,100 with severe oral disease.
PLEASE CHOOSE ONLY ONE OPTION
- Call me after the dental exam and provide an estimate of any additional procedures. I understand that if I cannot be contacted at this number, necessary radiographs, extractions or other dental procedures will be performed and my pet will be started on antibiotics and pain medication. I agree to assume financial responsibility for these additional charges.
- Call me after the dental exam and provide an estimate of any additional procedures. Do not proceed without authorization. I understand that if I cannot be contacted at this number no radiographs, extractions or other dental procedures will be performed and I will assume all responsibility for any complications this decision may cause for my pet. I also understand that if I decide to have these additional services done later, I have to schedule for a different appointment with separate charges.
Owner/Agent Consent*
I am the owner, or the owner's agent, of the above-described animal and I have the authority to execute this consent. I hereby consent and authorize the above procedures.
Medical & Surgical Complications Consent*
I hereby authorize Desert View Animal Hospital to perform the above procedures and additional diagnostic, treatments, or surgical procedures as deemed necessary for medical or surgical complications or otherwise unseen circumstances. I also authorize the use of appropriate anesthetics and other medications.
Liability Release*
The nature of the procedure(s) has been explained to me and no guarantee has been made as to the results of the procedure. I understand that there may be risks involved in these procedures and with any anesthesia or pain medication. I will not hold Desert View Animal Hospital, the Doctors, or the staff liable for any complications.
Should my animal unexpectedly require CPR or other life-saving emergency care at the hospital staff is unable to reach me, the staff*
- HAS my permission to provide such treatment and I agree to pay for such services at the time my bill is due.
- DOES NOT HAVE my permission to provide such treatment.
After Hour Care Acknowledgement*
I understand that hospital support staff will be used as deemed necessary by the veterinarian. I also understand that Desert View Animal Hospital is not staffed twenty-four (24) hours a day and after hour treatment of patients is at the discretion of the veterinarian.
Payment Acknowledgement & Consent*
Payment is expected when services are rendered, unless prior arrangements are made and approved in advance. Should I fail to pay at any time any portion of the bill for my pet's care, I agree to pay the costs of all delinquency charges, collection charges and reasonable attorneys' fees. Delinquency charges are 50% of the unpaid balance. I have read and understand this authorization of consent. I agree to pay the balance of the above estimated fees at the time of my pet's discharge
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Anesthesia and Dental Procedure Consent Form

Pre-anesthetic Lab Work

Intravenous Catheter and Fluids

Pre-anesthetic ECG Screen

Possible Additional Costs

Desert View Animal Hospital

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