Briarcliff Animal Clinic Too
1662 Virginia Avenue, College Park, GA 30337
404-835-1222
www.Collegeparkvet.com
Dental Admission Form
Client Name_____________________________________
Date: _______________________
Patient Name____________________________________
Procedure_______________________________________________________________________________________
Phone Number(s)*________________________________________________________________________________
*It is very important that we are able to reach you during the procedure to make timely
decisions in your pet’s course of treatment.
I do hereby authorize Briarcliff Animal Clinic Too to perform a dental procedure under general anesthesia, and declare
that I am the legal owner or authorized custodian of this animal. I release Briarcliff Animal Clinic Too, Dr. Peter J.
Muller III and all his agents or representatives of all legal responsibility for this animal.
I am aware of the risks involved in anesthesia. I understand that anesthetic or surgical complications may occur,
potentially resulting in medical problems or even death.
Pre-Anesthetic Bloodwork
Briarcliff Animal Clinic Too requires pre-anesthetic bloodwork to identify any underlying medical problems that may
cause complications with your pet’s anesthesia.
A CBC & Chemistry Profile (Glucose, BUN, Cr, ALP, ALT, TP) will be performed at
a cost of $103.00 unless it has been completed within 90 days of the procedure and are
available for the veterinarian’s interpretation.
Pain Management: It is the ethical standard of this hospital to provide pain management to every pet before, during and
after surgery. An injection will be administered to your pet prior to surgery and during the procedure to minimize your
pet’s discomfort. We may also provide oral pain medications for you to give at home.
IV Catheter and Fluids are required for all surgeries
During the procedure, additional problems may be discovered.
Permission is granted to:
1. Dental x-rays are used to assess any potential disease below the gumline. Please choose one of the following options:
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□
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Take dental x-rays and evaluate them to determine if any treatment is necessary. (recommended)
(Full mouth radiographs are $103.00)
Take dental x-rays only if an abnormality is detected on oral exam.
Take no dental x-rays, regardless of findings.
2. Oravet dental sealant is available for application after the dental cleaning. This product helps prevent plaque and tartar
build up. A take-home kit is available for purchase after the procedure and should be applied weekly.
Please apply Oravet dental sealant after the dental cleaning for a charge of $23.00.
Please send me home with an Oravet take-home kit for a charge of $46.55.
Yes
Yes
No
No
3. Please place a microchip in my pet during sedation of a charge of $85.00.
Yes
No
Signature ____________________________________________
Date__________________________