Client Name *

First

Last

Phone Number *

Email *

Pet's Name *

Species(Dog/Cat) *

Breed *

Age/Date of Birth *

Sex

Male
Female

Medical History:

Has your pet had any treats or food in the last 8 hours ? *

Yes
No

If so what time ? *

Is your pet experiencing any vomiting coughing ? *

Yes
No

Is your pet taking any medications ? *

Yes
No

If yes, please list : *

Elective procedures to be performed

Express and glands
Clean ears
Nail trim $0
Other

If other, please list : *

Intravenous catheter and fluids:
An IV catheter will be placed prior to anesthesia. IV fluids improve blood pressure, assist in processing the anesthetic agents, compensate for blood loss and provide a direct line in case of emergency.

Pre-anesthetic testing:
Your pet is scheduled for anesthesia and dental treatment. Any anesthetic procedure has potential risk. Therefore, we recommend a blood profile for all pets and require it for pets over 7 years of age, to ensure that your pet is in suitable condition prior to this procedure. We are able to perform quick and accurate blood tests before your pets anesthetic induction. these tests are same that your doctor would request before you would undergo anesthesia.

Please Choose One *

Recommended pre-anesthetic tests already been completed.
Yes: I hereby consent to the recommended mmended pre-anesthetic tests.
No: I decline the recommended pre-anesthetic tests. I understand the potential risks by omission of these tests. I assume full responsibility for my pet should complication.

If recommended pre-anesthetic tests already been completed, please mention date : *

Consent to perform extractions and necessary procedures:
A full dental exam is performed once your pet is under anesthesia. Until then we can not detect every dental problem your pet may have. A staff member will call you to update your estimate if additional services are needed. We recommend completing all needed dental procedures during this visit to help reduce stress on your pet and additional anesthesia costs.

Please choose one of the options below : *

Perform any needed procedures and/or extractions.
Call me after the dental exam and provide an updated estimate of an any additional procedures.

You can reach me at : *

If unable to reach me *

Do what is needed.
Provide only the requested dental plan as per my written estimate. I understand my pet will need to undergo another anesthetic procedure in the future.

Emergency Treatment:

In case emergency treatments are required while your animal is in our care. *

I authorize.
I do not authorize Southgate Animal Clinic to perform emergency treatment on my pet.

I agree to the above terms and conditions. I have reviewed the estimate provided to me and I agree to pay the full amount when my pet is discharged from a Southgate Animal Clinic. *

I agree

** All animals found to have an existing flea population will be treated with an appropriate flea product.

Today's Date *

Phone

Email

Online Pharmacy

Dental Treatment Consent Form

Dental Consent Form

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Location

Contact Information

Hours