CANINE 0-6 YRS
Bountiful Animal Pre-Anesthetic Dental Therapy Consent Form
Please Read Carefully, Initial, and Sign
Client: _________________________________
Patient: ________________________________
Age: ____________________
Emergency/Alternate phone numbers: ________________________________________________________________________
Procedure(s):_____________________________________________________________________________________________
_____ I certify that I am the owner/agent of the above animal and do hereby give consent to the Bountiful Animal Hospital to provide such
treatment as deemed essential by the attending veterinarian. This may include such things as hospitalization, surgery, anesthesia, or other
such treatments.
_____ Our greatest concern is the comfort and well-being of your dog, especially during treatment. I understand that although the anesthetic
and surgery protocols used today are relatively safe, there is always a potential risk associated with their use. I agree not to hold the Bountiful
Animal Hospital veterinarians and staff liable for any untoward events or complications that may occur in the absence of gross negligence.
In the event that my animal arrests while hospitalized at Bountiful Animal Hospital I authorize the following CPR code:
_____ Normal CPR: involving chest compressions, oxygen therapy and medications such as epinephrine, atropine, etc.
_____ DNR: No resuscitation
Certain medical conditions that may not be evident on a routine physical exam can potentially complicate the risk to your dog when put under
anesthesia or through surgery. Bountiful Animal Hospital offers and recommends a pre-anesthetic blood profile be performed in order to
screen the major organ systems, ie. liver, kidneys, glucose, for such problems. At this time blood work is optional. Blood work is required for
animals 7 years and over.
Accept Blood Work Options: 10 Panel $78________ 15 Panel $93 ________ CBC $76 ________
Decline Blood Work ________
_____ I understand that because my dog will be undergoing surgery for dental work, medications for pain and inflammation will be
administered if deemed necessary by the veterinarian. I also understand that any teeth causing compromise to my dog’s oral health will be
extracted while my dog is under anesthesia.
If any teeth are chipped, fractured, have large pockets, or drainage tracts, our hospital is able to take diagnostic dental x-rays. These x-rays
present information on the teeth under the gum line, helping to determine if a tooth can be kept or needs extracting. (Cost: first x-ray $30,
additional x-rays $19, with a cap at $90, or full Mouth Small Dog $125 Medium to Large Dog $140)
Accept Dental x-rays (only problem teeth) ________
Full Mouth Dental x-rays ________
Decline Dental x-rays ________
Laser Therapy: Application of the therapy laser after your pet has undergone dental extractions and/or the gums are inflamed greatly
enhances tissue healing and reduces pain and inflammation.
Accept Laser Therapy $25 ______
Decline Laser Therapy______
Vaccinations: An important aspect in keeping your dog healthy is administering annual vaccinations. We recommend clients keep their dog
current on all necessary vaccinations.
** Administer vaccinations at this time: DHPPL w/ Oral Bordetella $42________
Influenza $33 or $58 ________
RABIES $34 or $22 ________
_____ Decline vaccinations at this time and understand the risks involved.
_____ Pet is current on vaccinations at this time.
I further realize that I am responsible for payment in full at the time the animal is discharged. If I neglect to pick up the animal within five days
you may assume that the pet is abandoned. At this time, Bountiful Animal Hospital will assume ownership of the animal and do what is
deemed best and necessary. Abandonment does not release me of my obligation for the bill. I further agree that in the case of non-payment,
a finance charge of 1.5% per month will be charged and any collection fees or attorney fees will be my responsibility.
_____________________________________
Owner/Agent Signature
________________
Date
**Forms of Payment Accepted: Cash, Visa, Mastercard, Discover, Care Credit**
***No Checks or American Express accepted***