Dental Authorization Consent - Pend Oreille Veterinary Service

Client Name(Required)

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Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

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Patient's Name(Required)

Species(Required)

Breed(Required)

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Our goal is your pet’s care and comfort. To help ensure your pet’s SAFETY AND COMFORT before
and after their procedure, we offer the latest in diagnostic and post-operative care options.

PRE-ANESTHETIC DIAGNOSTIC OPTIONS

A complete physical exam will be performed on your pet prior to the procedure. However, this may not
identify all systemic or metabolic problems. To ensure the safety of your pet we recommend specific pre-anesthetic diagnostics which include:

Pre-Anesthetic Blood Panels to determine function and health of kidneys and liver as well as determining white and red blood cell counts, glucose and electrolyte levels. In geriatric or at risk pets the doctor will recommend a more in-depth blood panel to also test pancreatic function and/or thyroid function.
2 X-rays to survey your pet’s heart, lungs and/or abdomen. May also be used to determine arthritic changes in your pet.
EKG to detect any underlying heart abnormalties or dysfunction’
Coagulation Panel to ensure clotting factors are adequate

Choose our pre-anesthetic diagnostic SAFETY PACKAGE and receive a 20% discount for all three. Or
you may choose individual items at full price.

Packages

Pre-Anesthetic Safety Package $369.80

or choose individual options below

Blood Panel Options:

Pre-Anesthetic $103.90

Coag Panel: (included in Safety Package) $67.45

General Health Panel (included in Safety Package) $131.60

other options

EKG (included in Safety Package) $101.85

X-rays (included in Safety Package) $162.30

Decline all recommended diagnostics:

Full Mouth Dental X-ray

Full mouth dental radiographs allow us to find painful lesions below the gum-line such as bone loss, abscess and
tooth resorption. Post-extraction x-rays make sure all of the tooth and root have been removed.
Single dental x-ray fee will be charged for all extractions ($18.35)

Full mouth dental x-ray fees are :
Cats/ small dogs (under 20 pounds) $101.70
Medium dogs (21-50 pounds) $128.80
Large dogs (over 51 pounds) ) $169.40

If full mouth radiographs are accepted, no additional fee for post-extractions will be charged

Dental xray(Required)

I give my permission:

I do not give my permission:

Tooth Extraction(Required)

If teeth are severely diseased or fractured, extraction of the teeth may be the best option for the health and comfort of your pet. We will make every effort to contact you in this event. If we are unable to contact you, we require permission to proceed with the extraction.

I give my permission:

I do not give my permission:

PAIN CONTROL AND INCREASED COMFORT OPTIONS

We care about your pet’s comfort during and after surgery. To give our patients the highest standard of care we offer multiple comfort options to aid in your pet’s healing. The options available to your pet are individually tailored based on the health status of your pet and the procedure to be performed.

Peri-operative pain control can include anti-inflammatory injections, local nerve blocks and long acting nerve blocks.
Post-operative medications provide your pet relief from the discomfort of surgery as well as helping in recovery and healing.
Occasionally post-operative sedatives are indicated to help keep your pet calm and quiet during the
recovery process.

We are also proud to offer Laser Therapy, which is proven to help promote healing of tissues when applied to the surgical site upon completion of the surgery.

Pain Medication(Required)

Yes

Meds

Tablets

Liquid

Transdermal (Cats Only)

Post-Operative Sedatives:(Required)

Yes

Laser Therapy

Yes

Local, Short Acting Nerve Blocks (when indicated) $43.50:

Yes

Long-Acting Nerve Block/Nocita (when indicated)

This is a newer extended-release local nerve block can be instilled into the tissues at the surgical site or for dental extractions. It provides 72 hours of pain control at the surgery site. Cost is based on the quantity used which is determined by the size of the patient and the extent of the surgical site. Costs are approximate and will not exceed the listed amount.

Cats $19-30
Dogs <22 lbs $19-60
Dogs 22-44 lbs $60-120
Dogs 44-88 lbs $120-240
Dogs >88 lbs $200-300
* Dog Spays and Neuters (any size) $15-75

Yes

MICROCHIP OPTIONS(Required)

For the protection of our pets the insertion of a microchip is recommended but optional at the time of your pet’s anesthetic procedure

I authorize microchipping $66.60

I do not authorize microchipping

REGARDING PATIENTS STAYING OVERNIGHT IN THE HOSPITAL:

At Pend Oreille Veterinary Service we do occasionally keep surgery patients in the hospital overnight prior to, or after surgery. Every effort is made to make our environment as safe and comforting as possible for your pet. However, we do want clients to be informed that we are not staffed 24 hours/day. Your pet will be unattended overnight until the morning staff arrives. Based on availability, we can sometimes arrange a technician to stay overnight with critical patients. For 24 hour monitoring we recommend transport to a fully staffed emergency clinic. There are emergency clinics in Coeur d’Alene, Post Falls and Spokane. Our doctors and staff are available to answer any questions you have regarding your pet’s overnight care.

RECEIVING UPDATES REGARDING MY PET:(Required)

In the event the doctor has questions or concerns regarding your pet, they will call you on the number(s) listed below. If unable to reach you, the doctor will use their clinical judgement regarding your pet’s care. In regards to routine updates (such as completion of surgery or to confirm discharge time), would you like to be contacted via:

Phone call only

Text and/or picture message to the number listed below

E-mail

Authorization(Required)

I, the owner or agent of the pet identified above, certify that I am over 18 years of age and authorize the staff of Pend Oreille Veterinary Service to perform the above procedure(s). In signing this form I am also giving Pend Oreille Veterinary Service permission to treat my pet as deemed necessary on the basis of the veterinarian’s findings during the course of the examination and evaluation; understanding that there is no guarantee that treatment will be successful and Pend Oreille Veterinary Service will not be held liable for any loss that may occur. I acknowledge that staff members at this practice have explained the procedures to me, answered questions to my satisfaction and cannot be held responsible for any unforeseeable results. Furthermore, I understand that I am financially responsible for all costs incurred during this surgery treatment and hospitalization. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, recheck physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have read and fully understand the terms and conditions set forth above.

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