Pet Details

Pet Name(Required)

Name

Breed(Required)

Species(Required)

Sex(Required)

Male

Female

Male Neutered

Female Spayed

Weight

Date of your pet's appointment(Required)

Owner Details

Name(Required)

First Last

Address

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

Email(Required)

Phone number where you can be reached AT ALL TIMES the day of your pet's procedure *(Required)

Does this number accept text/SMS? *(Required)

Yes

Please do not text - phone calls only.

Secondary phone number (and name of contact if different than you)

Does this number accept text/SMS?

Yes

Please do not text - phone calls only.

Patient Medical History

Please list all medications or supplements your pet is taking - include 1) Name of item 2) Dosage 3) Time last given(Required)

Any known reactions or allergies to medications or vaccinations?(Required)

Yes

If yes, Please describe:

Has your pet shown recent signs of illness such as vomiting, diarrhea, coughing, or sneezing?(Required)

Yes

If yes, Please describe:

Has your pet shown changes in appetite, drinking or exercise habits?(Required)

Yes

If yes, please describe:

Please list any other concerns about your pet:(Required)

Please list any belongings left with your pet (The clinic will not be resopnsible for lost items.):(Required)

Please list any behavioral or handling concerns (fear biting, dog aggression, pain, etc.):(Required)

PRE-ANTHESTIC TESTING

A veterinarian will perform a physical exam to assess your pet's overall health prior to giving any anesthetic medications. To better assess internal organ health we offer a pre-anesthetic blood panel to be performed prior to the procedure. See the attached form on blood panels for details. For patients under 7 years of age, this is optional for clients. It is important to understand that pre-anesthetic profile does not guarantee the absence of complications. It may, however greatly reduce the risk of complications and identify medical conditions that could require medical treatment in the future.

For patients under 7 years old:

Please proceed with pre-anesthetic blood testing

I decline the recommended pre-anesthetic blood work and understand there may increased risks during anesthesia

In patients 7 years and older NSVC requires Pre-anesthetic blood profile and measurement of blood pressure Within 3 months of the procedure.

ORAL SURGERY CONSENT

Once your pet is anesthetized the veterinarian will thoroughly examine your pet's teeth and gums and review dental x-rays. Your veterinarian will then call you with these results and discuss any recommendations. If any advanced dental work (Such as a tooth extraction) is recommended, an updated estimate on cost will be provided. If your veterinarian is unable to contact you or your authorized agent, we need to know your preferences.

If contact cannot be made at the phone numbers provided within 15 minutes, I prefer the following:(Required)

Proceed with all recommended procedures, including tooth extractions, as determined by the doctor.

Proceed with recommended procedures including unforeseen tooth extractions up to certain amount.

Do not extract any teeth or perform any additional treatments other than exam, cIeaning and polishing. I understand that no oral surgery will be performed, and an additional anesthetic procedure may be needed (that may increase the cost of treatment).

I prefer my pet be referred to a board-certified veterinary dental specialist for all procedures, and do not authorize any treatments or extractions.

If you chose for us to proceed up to a certain cost amount, please enter that dollar amount here:

ADDITIONAL SERVICES

I would like NSVC to perform these additional treatments while my pet is in the facility:

Nail trim

Ear Cleaning/Flush

Anal gland draining/expression

Microchip Placement

Fluoride Treatment

Give Vaccinations Due

OralVet Application - (Dental sealant that helps prevent bacteria and tartar build up)

POST OPERATIVE CARE

Pain control:(Required)

I prefer giving oral tablet medications.

I prefer giving oral liquid medications.

I am unable to give any oral medications and prefer you give my Pet injection medications when possible.

The information provided on this form is true to the best of knowledge. I verify that I am the owner (or Authorized agent for the owner) of above named pet and authorize the above procedure to be performed. I authorize the use of anesthesia and other medications as deemed necessary by the veterinarian and understand the hospital personnel will be employed in the procedure(s) as directed by the veterinarian.

I have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any anesthesia episode, even in apparently healthy animals and have discussed my concerns with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I herby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian's professional judgement. I accept responsibility for any result in additional charges. I agree to be responsible for any charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital.

Client's Signature(Required)

Date

Phone

This field is for validation purposes and should be left unchanged.

Dental Consent Form

Pet Details

Owner Details

Patient Medical History

PRE-ANTHESTIC TESTING

ORAL SURGERY CONSENT

ADDITIONAL SERVICES

POST OPERATIVE CARE

Why Choose Us

Request a Refill

Schedule a Visit

Get in Touch