Dental Consent

please complete the form below

CLIENT INFORMATION

First Name (required)

Last Name (required)

Address (required)

City (required)

Zip Code (required)

Email (required)

Phone (required)

My pet is having the following procedure today

PET INFORMATION

Name (required)

Breed (required)

Age (required)

Species
CanineFelineOther

Is your pet

Having any vomiting?
NoYes

Having any diarrhea?
NoYes

Having any coughing?
NoYes

Having any sneezing?
NoYes

Have you noted that your pet is experiencing weight loss?
NoYes

Is your pet experiencing any pain?
NoYes

Pet's appetite?
IncreasedDecreasedNo change

Pet's drinking?
IncreasedDecreasedNo change

Pet's urination?
IncreasedDecreasedNo change

MEDICATION/SUPPLEMENTS

If your pet is on any medications, please list drug names, dose, and how often they are administered, or write none. (required)

If your pet is taking any supplements, please list supplement names, and how often they are taken, or write none. (required)

Does your pet have any known medication allergies?
NoYes

Does your pet have any previous medical conditions?

If your pet needs medications to go home after their procedure, do you prefer
TabletsLiquidLong lasting medications administered in hospital before discharge

The last time my pet ate was: (required)

I authorize Folsom Ranch Veterinary Hospital and Urgent Care to perform an anesthetic dental procedure (radiographs, dental cleaning, and exam) on my pet. I understand that this procedure involves the administration of anesthesia, which carries certain risks, including but not limited to adverse reactions, respiratory issues, cardiac arrest, and, in rare cases, death.I acknowledge that the veterinary team will take all necessary precautions to minimize these risks and monitor my pet closely throughout the procedure. I understand and I assume all risks and will not hold Folsom Ranch Veterinary Hospital, the Veterinarians or any staff member liable for any complications should they arise. I understand that I am responsible for all costs involved and payment is required for all services at the time they are rendered. Lastly, I understand that during the dental procedure, it may be necessary to extract teeth that are diseased or causing pain.

I AUTHORIZE THE FOLLOWING TREATMENTS
Please select one of the following:

I approve any treatments necessary today Including any extractionsI approve any treatments necessary up to an additional $500 over the provided estimate. If additional treatment exceeds this amount I would like to be called first to approve.I approve any treatments necessary up to an additional $1000 over the provided estimate. If additional treatment exceeds this amount I would like to be called first to approve.Do nothing more over the provided estimate unless you reach me by phone. I acknowledge that if I select this option and I do not answer the phone my pet WILL be woken up without receiving the necessary recommended treatments and my pet MAY need another anesthetic procedure to complete any treatments recommended by the DVM. This additional anesthetic procedure will be my financial responsibility.

CONSENT & AUTHORIZATION FOR LIFE SAVING TREATMENTS

In the unfortunate event that your pet experiences a cardiopulmonary arrest (his/her heart stops or he/she stops breathing on their own), we at FRVH need to know you and your family’s wishes on how you would like us to respond. Some families choose for us to pursue CPR (cardiopulmonary resuscitation) in an attempt to re-establish your pet’s heartbeat. Due to many understandable circumstances, some families ask that CPR is not pursued, designating their pet at DNR (do not resuscitate). Please know that we support and respect your family’s decision regardless of your reasoning.

Please select one of the following:

I wish to select CPR, including chest compressions and manual ventilation. I acknowledge the risks associated with CPR and consent to the initial resuscitation charges of $500-1000, knowing this total may substantially increase if extensive intervention is needed to recover my pet.I wish to select DNR, acknowledging that no life-saving measures will be deployed should my pet’s heartbeat or breathing capabilities stop.

CONSENT

I am over 18 years of age and am the authorized owner and-or guardian for the aforementioned patient. I authorize Folsom Ranch Veterinary Hospital and Urgent Care (FRVH) to perform treatment/procedure(s) on my pet(s) as recommended by FRVH's Veterinarians and employees. I was informed of the reasons for the treatment/procedure(s), along with the expected benefits and risks involved. I confirm that by signing below, I understand the inheritable and sometimes unforeseen risks associated with veterinary care and release all liability, without exceptions, from Folsom Ranch Veterinary Hospital (FRVH) while treating my pet(s). I understand that payment is required for all services at the time they are rendered unless prior arrangements have been made with hospital management. I understand that deposits may be required prior to certain procedures. In the event that a refund is due and the original payment is a credit card, the refund will be posted against the original credit card. I also authorize FRVH to use pictures of my pet(s) for learning or marketing purposes. Consent will apply to all future pets added to this account unless and until I provide a written revocation of that consent.

SIGN BELOW