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Owner's Name

Pet's Name

Email

Mobile Phone

Secondary Phone

Items left with patient:

Additional Procedures:

Statement

Consent for General Anesthesia and Dental Procedures:

By submitting this form, I confirm I have been given an explanation and understand the nature of the dental procedure and the risks involved. I also understand that there are risks associated with anesthesia. If unforeseen conditions or complications arise during the procedure, Towne Animal Clinic will attempt to contact me. If I cannot be reached I give my consent for Towne Animal Clinic to take the steps necessary in the best interest of my pet.

The degree of dental disease cannot be fully assessed until my pet is under anesthesia. At that time diseased teeth are often found and may need additional treatment or extraction; often X-Rays are needed to make these treatment decisions. The approximate costs for these procedures are:

Major tooth extraction: $168.75-295.50
Minor tooth extraction: $55.25
Periodontal Treatment $77.52-99.00
Dental X-Ray Series (unlimited number): $132.75
Gingivectomy $100.00

*Please contact us ahead of time if you have any questions about cost confirmations.

I authorize x-rays, treatment and/or extraction of diseased teeth if the doctor feels these are appropriate.

Accept
Decline
Call First

If I cannot be reached, I:

Would like the doctor to proceed with x-rays/extractions as recommended.
Would like the doctor to wait until I can be reached.

Acceptance

I understand that if I decline tooth extractions and dental x-rays or if the doctor is unable to reach me at the above number(s), a second anesthetic procedure may be necessary to address these problems.

I acknowledge and agree to the terms and conditions of service

Other

Please indicate if you would like any of the following performed. *Select only one blood draw option.

Pre-anesthetic Blood Screen ($116.00)

A minimum, recommended for all pets undergoing anesthesia. Helps detect underlying conditions that might increase the risk of anesthesia or surgery. If there are abnormalities, the veterinarian will contact you prior to anesthesia and appropriate steps will be taken to ensure the safety of your pet.

Accept
Decline
Questions

Complete Blood Panel ($178.40)

Recommended for pets 7 years and older. This blood panel is more comprehensive than the pre-anesthetic blood screen and can detect a more complete range of age-related problems.

Accept
Decline
Questions

Pre-anesthetic ECG for Dogs and Pro BNP blood test for Cats ($91.90)

Recommended for all pets, especially ones 7 years or older. An ECG for Dogs and Pro BNP for Cats can reveal potential problems with heart function and disease. If any abnormalities are evident, we will contact you prior to anesthesia.

Accept
Decline
Questions

Microchip Identification ($76.75)

Recommended for all pets. This chip is implanted under the skin between the shoulder blades, it allows veterinary hospitals and shelters to identify your pet if lost or stolen. Identification is done via a special scanner that reads the chip and displays your pet’s unique ID number. Our fees cover the cost of the chip and implantation. Lost pet registration is included at no additional charge.

Accept
Decline
Questions

Optional Services

As a courtesy, we will trim your pet's nails at no cost. Please feel welcome to select any of the following additional services you would like to purchase for your pet at additional cost.

Clip matts
Express anal glands
Clean ears
Pluck ears