Dentistry Release Form in Belle Vernon, PA

Owner*

First Last

Patient's Name*

Address*

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

Species*

Canine
Feline

Who can be reached on the day of the surgery?*

Name	Number	Cell / Home / Work

It is not possible to thoroughly evaluate the teeth and gums until your pet is anesthetized. Each tooth must be evaluated before a decision is made as to the best course of treatment. The teeth are cleaned with an ultrasonic scaler to remove tartar. After that a dental probe is used to check around each tooth. If problems are found then dental x-rays may be needed to determine the extent of the problem. Any teeth that are fractured or have missing enamel may need to be extracted (here), or need root canal therapy done elsewhere at a later time. In addition, any tooth that is loose or where the bone around the tooth roots has been lost from periodontal disease should be extracted. Cats develop cavity-like lesions at or below the gum line and the only treatment for these painful teeth is extraction. After the oral examination and possible x-rays the doctor or technician can call you (as indicated below) about any problems found and discuss the options for whatever further oral surgery is indicated. The oral surgery may be able to be done at this time or scheduled for another date. It is more economical to complete all needed dental procedures during the initial anesthetic session rather than schedule a separate procedure at another time.

The following choices are available:*

The doctor has permission to do whatever treatments or extractions are deemed necessary
I would like to be contacted prior to any extractions.

After the initial cleaning is done and problems have been addressed, the teeth are polished, the gums are flushed with antiseptic and a fluoride treatment is applied. Antibiotics and pain medications are prescribed as needed.

A geriatric blood profile is REQUIRED for geriatric patients or patients with health problems before undergoing anesthesia.

Pre anesthetic blood screening is recommended for ALL patients, but is optional. If your pet is under 8 years of age, please accept or decline the below recommended procedure:

Pre-anesthetic bloodwork for healthy patients under 8 years of age

Yes
No

Date

I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL SERVICES RENDERED.*

Type Name

ANY patient that is hospitalized is required to have a current rabies and distemper vaccine. If there is no proof of vaccine upon admission, your pet will be vaccinated while hospitalized and charged accordingly!