Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Contact Phone Number *

Other

Emergency Contact Name

Phone Number

PET INFORMATION

Pet’s Name

Breed

Color(s)

Age/Birth Date *

Species *

Dog
Cat
Other

Other *

Sex *

Male
Female

Procedure to be performed *

Dental Cleaning
Oral Surgery
Other

Any pet that is found to have fleas will be given a Capstar pill to kill all fleas on the patient. ($10-12)
A current Rabies vaccine is required on all patients ($20)

Other *

I am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consent.

I have been informed that there are certain risks and complications associated with any operation or procedure of this type. They have been explained to me as well. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures.

I authorize the use of appropriate anesthesia and pain relief medications as needed before or after the procedure. I have been informed that there are risks associated with the use of any medication.

I understand the clinic support personnel will be used as deemed necessary by the veterinarian.

I am also aware that arising complications will not relieve my financial obligation for any and all costs incurred for emergency procedure performed in the event complications may arise. I accept full financial responsibility for any and all services incurred and understand payment in full is due at the time of patient discharge.

In the event your pet’s condition becomes critical, please check one of the following options

I authorize Vidalia Veterinary Clinic to perform emergency and/or lifesaving treatments and diagnostics on my pet. I agree that I will be responsible for any incurred expenses regardless of the outcome. (CPR)
I do NOT authorize Vidalia Veterinary Clinic to perform emergency and/or lifesaving treatments and diagnostics on my pet. I understand and accept that my pet may die if no intervention is taken. (DNR)

Date *

Optional Services: Please accept/decline the following services to be performed on your pet.

Dental Radiographs: We highly recommend dental radiographs, because 60 % of the tooth is under the gum line where we cannot see. The radiographs would allow us to see any damage that would indicate the need to repair or removal of damaged teeth. Leaving diseased teeth can cause pain, inflammation, and infection. It is against our medical advice to decline this service.

I want full mouth dental radiographs ($125).
I want dental radiographs on visibly damaged teeth ($25 per tooth).
I do not want dental radiographs for my pet.

Extractions: Extractions are the removal of teeth. Teeth that are loose, broken, or diseased should be removed. Leaving diseased teeth can cause pain, inflammation, and infection. It is against our medical advice to decline this service.

I want the veterinarian to proceed with extractions needed once dental radiographs are performed and accept all additional charges incurred.
I wish to be contacted to discuss extractions. If I cannot be reached, I authorize up to $
I do not want to proceed with extractions and wish to only have my pet’s teeth scaled and polished.

in additional cost of the high-end of my estimate to go towards extractions.

Pain Medication- In the event of extractions, additional pain medication to go home is HIGHLY recommended. It is against our medical advice to decline this service.

I want oral pain medication to go home (starts at $15+).
I do not want oral pain medication for my pet.

Pre-Anesthetic Lab Work- Basic pre-anesthetic lab work including 14 Body Chemistry Function Parameters and a Complete Blood Cell count (CBC) is recommended on EVERY pet undergoing general anesthesia and mild sedation. This blood work is required for pets 7 years of age and older, as well as obese patients of any age. This lab work checks the pet’s basic kidney and liver function, blood glucose, protein levels, and white and red blood cell concentrations and can help minimize the risk of complications from medical conditions not evident during a physical examination. Based on the age/condition of the pet, additional or more involved lab work prior to anesthesia or sedation may be required. It is against our medical advice to decline this service.

I want pre-anesthetic blood work ($75).
I do not want pre-anesthetic blood work for my pet.

Anti-Nausea Injection- We recommend an anti-nausea injection to prevent nausea and vomiting often resulting from anesthesia. Studies have shown faster recovery and return to normal eating habits in pets receiving this injection prior to anesthesia.

I want the anti-nausea injection ($28.50-75.50).
I do not want the anti-nausea injection for my pet.

Date

List (2) working telephone numbers you can be reached at today for updates on your pet or in case of an emergency

Dental Consent Form