Dental Consent Form Date Of Appointment* Owner* First Last Pet's Name*Procedure(s):*Please initial the following:To the best of my knowledge my pet is in good health.My pet last ate at: (initial after response)*When did your pet last receive their medications?*A physical exam will be performed on your pet prior to the procedure, but this may not identify all internal problems. It is good medical practice to perform pre-operative blood work to assess major organ function and check for other blood abnormalities. Blood work is required for pets over the age of 8.*Accept Pre-Operative Blood Work ($100)Decline Blood WorkDogs receiving monthly heartworm preventative must have had a negative heartworm test within the past year. Dogs not receiving heartworm preventative must be tested for heartworm (unless they are less than 6 months of age).*Accept Heartworm Test ($35-45)Decline Heartworm TestN/ANow is the perfect time to implant a microchip!*Accept Microchip ($45)Decline MicrochipN/AAny other services desired such as anal gland expression?***In some cases, a tooth may be able to be saved with techniques such as root canals or crowns and a referral can be made to a dental specialist at that time, is this something you would be interested in? ***YesNoPeriodontal Treatment is a long-lasting antibiotic gel that can be applied to teeth that are infected (have a pocket), but otherwise are healthy. It stops the progression of the infection (which leads to periodontal disease) and can even close the pocket.*Accept Periodontal Treatment (~$10.00/tooth)Decline Periodontal TreatmentA free nail trim will be performed. If we find external parasites (fleas, etc.) on your pet, we will treat your pet and the cost of the treatment will be added to your invoice.I, the undersigned, certify that I am the owner, or authorized agent for the owner of the animal described above. I authorize the veterinarian and assistants of Mahomet Animal Hospital to perform the procedures listed above. I understand that no surgery and no anesthesia is without risk of complications and that, although rare, there is always the possibility of loss of life. I release Mahomet Animal Hospital and its associates from any liability in such an event, i.e. injury, escape, death, or any other unforeseen circumstances. I also understand that no guarantee of successful treatment can be made. In the event of an emergency I authorize the veterinarian and assistants to provide any and all treatments/procedures deemed necessary and accept responsibility for any additional cost incurred. (Signature)*Date* Phone(s)*Payment is due when services are rendered, unless prior arrangements have been made. Account balances will be charged a $1 statement handling fee and 2% interest accrued monthly.EmailThis field is for validation purposes and should be left unchanged.