Dental Release Form

Congratulations on deciding to clean your pet's teeth. As with any procedure requiring anesthesia, there is risk. The more information we can obtain about your pet the less the risk.Base price includes the cost of the procedure (teeth cleaning), anesthesia, IV catheter and fluids, and dental evaluation.

*Indicates Required Field

Pet Owner Information:

Owner's Name*

Best Number to Reach You By*

Owner's Email (recommended)

Pet Information:

Pet's Name*

Pet's Sex*
SelectMaleFemale

Species*

Pet's Breed*

Pet's Age*

PREOPERATIVE BLOODOWORK: We recommend a pre-anesthetic blood chemistry screen on all pets prior to anesthesia. Most anesthetic drugs are removed from the body by the liver and kidneys, therefore it is important that these organs are healthy. Underlying conditions are those where clinical signs are not apparent but problems could occur when anesthesia is performed. The tests include a complete blood count and serum chemistries profile. The additional cost for this full CBC/Chemistry panel is $132. Would you like us to perform pre-operative bloodwork on your pet?*
YesNo

POST-PROCEDURE MEDICATION: Post anesthetic anti-inflammatory injection helps with pain and discomfort following procedure, and costs $40. Would you like us to administer anti-inflammatory medication for your pet after the procedure?*
YesNo

ORAVET KIT: The Oravet take-home kit helps prevent plaque and calculus formation, and costs $50. Would you like a kit?*
YesNo

DENTAL X-RAYS: Full mouth dental x-rays can be done to help prevent and diagnose disease and cost $77 for dogs and cats. Would you like to opt-in for x-rays for your pet?*
YesNo

I understand that reasonable precautions will be used against injury, escape, and death of my pet. All anesthetics do present a risk to the health and life of my pet. I accept these risks as part of the procedure. I realize that results cannot be guaranteed, and that payment is due in full at the time of discharge. By signing below, I indicate that I understand and do agree to the above information.

Client Signature*

Today's Date*