Cypress Creek Animal Hospital

Date

Client

First Last

Patient

Your pet is undergoing a dental procedure today. This will involve General Anesthesia and may also involve:

Cleaning the teeth
Extracting the teeth
Procedures involving single teeth, or
Application of a long-lasting antibiotic underneath the gumline.

In general, pets undergoing a dental cleaning receive a thorough cleaning and polishing of all the teeth. However, if the teeth are very bad, several or many of the teeth may need to be extracted. Some pets also benefit from pre-anesthetic blood work, IV fluid therapy, or post-operative pain medication depending on the procedures performed on your pet. Oftentimes, it is difficult to determine the needs of the pet until he or she is under anesthesia. Please talk with a veterinarian at the clinic if you have any questions about the possible needs of your pet. In order to more accurately meet the needs of your pet and also to honor your wishes and financial concerns, we ask you to please choose from one of the options below:

Please perform any necessary procedures for my pet, including cleaning, polishing the teeth, removing any diseased teeth, IV fluid therapy if needed, and medication administered or prescribed for post-operative pain.

Please only perform the following procedures that you and the veterinarian have discussed and are listed below:

Dental Cleaning
Oravet Plaque Prevention

Please only perform a dental cleaning on my pet. I do not want any other procedures performed on my pet, including any extractions or other procedures that might be indicated.

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Phone number where you can be reached

Laboratory Test and Pain Medication Waiver

Pre-anesthesia Blood Screen: If your pet is to be anesthetized, rest assured that advances in anesthesia and surgery have made routine procedures relatively safe with a low rate of complications. Nevertheless, occasional problems can arise due to pre-existing conditions not evident during routine pre-anesthetic examinations. To avoid these problems, we recommend that your pet be screened prior to anesthesia by means of the following laboratory test. This blood screen checks for conditions such as anemia, diabetes, kidney or liver failure, and other potentially serious underlying problems. This test will be performed (and you will be billed for it) unless you refuse it by initialing and signing below.

Pain Medication: A certain amount of pain is to be expected with your pet’s surgery today. We feel every attempt should be made to eliminate this pain. An injectable pain medication will be given at the time of surgery and oral pain medication will be sent home with your pet.

Initial for Refusal

Pre-anesthesia Blood Screen $71.50
Pain Medication $33.55 - $46.75 (depending on weight)

Please enter the below:

Dental Consent Form

Cypress Creek Animal Hospital

Laboratory Test and Pain Medication Waiver