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Today:
8:00 am - 6:00 pm
Open Hours
(972) 775-2901
Phone Number
840 E Main St
Midlothian, TX, 76065
Request an Appointment
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today:2023-10-02
Dental Surgery Form
Client Name
Client Phone Number
Patient Name
I, the undersigned owner, have been informed that my pet is in need of preventive or therapeutic dental care and hereby consent to the appropriate procedures described to me by staff veterinarians at this facility. These procedures include but are not limited to the following:
1) dental prophylaxes (routine teeth cleaning and polishing)
2) extractions
3) oral surgery to close gaps left by extractions. I am aware that dental procedures for animals require the use of anesthesia to:
1) maximize visualization of the gums, teeth, and oral cavity
2) minimize movement and discomfort, and
3) provide for the safety of the pet, doctors, and hospital staff. I understand that some risks always exist with anesthesia and dental procedures and that I am encouraged to discuss any concerns I have about those risks with my attending veterinarian before these procedures are initiated. I understand the doctor and staff will use all reasonable precaution against injury, escape and/or death of my pet. I understand that all anesthetics involve some minimal risk to my pet and I will not hold the doctor or staff responsible under any circumstances. I understand I assume all risks. I have been informed that examinations under anesthesia often reveal abnormally loose teeth that fall out or should be extracted to prevent oral discomfort and ongoing infection of surrounding bone. I also have been informed that the loss or removal of one or more unhealthy canine teeth occasionally allows for an awkward protrusion of the tongue to one side or the other. If my pet has more than _______ such teeth that should be extracted, I request that a staff member contact me for authorization or information about other options. If I cannot be reached within 10minutes while my pet is undergoing anesthesia and dental care, no further services will be rendered at that time.
0 Teeth
1 Tooth
2 Teeth
3 Teeth
No Need to Call
Your pet will be undergoing general anesthesia plus a surgical procedure today. In order to recognize any underlying abnormalities your pet may have, we recommend having a pre-surgical blood profile run on your animal. This consists of a check of the ELECTROLYTES, CBC, which will check blood cells, and an ALT, ALKP, CREA, GLU, TP, and BUN, which will check blood glucose, kidney and liver enzymes.These blood tests will help us to assess the health status of your pet more completely and determine if there are any additional precautions we need to take before surgery. We highly recommend a blood profile for animals over 5 years of age. There is an additional charge of $95.00 for these blood tests. We hope you understand the need for these important tests. This is a requirement if your pet is over the age of 7 years.
Yes, please run pre-surgical labwork
No, I understand the risk of anesthesia without labwork.
No, my pet has had labwork within the last 30 days at Midlothian Veterinary Clinic.
Would you like to add: Microchip Implantation $63.66 (Includes 1st year of service)
Yes
No
No, pet already has a chip, please verify number
Laser Therapy (Post-Op) $14.29
Yes
No
Please leave any additional notes or concerns you may have for the doctor.
Please leave this field empty.
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