DENTAL PROPHY ADMITTING FORM
Studies show that 60-80% of all pets over the age of three years have periodontal disease and need
dental care.
Dental disease in pets causes many problems such as:
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Bad Breath
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Infections Spreading To Internal Organs (Liver, Kidney, Heart)
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Mouth & Gum Pain
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Loss of Teeth
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Future Owner Expense
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Potential Infection Spread To Humans ("Conjunctivitis")
Proper Dental Cleaning Procedures Include:
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Pre-Sedation Physical Examination by the veterinarian.
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Pre-Sedation Blood Profile Screening (Optional, if your pet is <5 years old, but highly
recommended)
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Sedation & Vital Sign Monitoring
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Ultrasonic Scaling and cleaning of the teeth ABOVE and BELOW the gumline.
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Antiseptic Flushing To Remove Bacteria
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Teeth Polishing To Smooth Surfaces After Scaling
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Fluoride Application To Strengthen Teeth & Build Resistance To New Tartar
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Recovery Day Care Hospitalization
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Long Acting Antibiotic Injection and any pain medications needed.
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Are Vaccinations Current? HW Test Current?
 Update Today
Any Vomiting, Coughing, Sneezing, Diarrhea?
Did Your Pet Eat This Morning?
Is Your Pet Allergic To Any Drugs?
What? ___________________
Has Your Pet Had Any Accident Or Illness In Last 30 Days?
Is Your Pet Currently On Any Medication?
What? ___________________
Any Other Specific Problems To Be Checked?
What? ___________________
Any Dental Hygiene Products Used On Regular Basis? What?
Do You Need A Refill On HW Medication Or Frontline Today?
ELECTIVE PROCEDURES TO BE DONE AT THE SAME TIME
Dental Admit Information
These are simple procedures that do not greatly increase sedation/anesthesia time and therefore can be
provided at a fee less than would be required otherwise (when sedation would be required for the
separate procedure) when done at the same time as the dental prophy:
[] Microchip ID
 Comprehensive Physical Examination
[] Deworming
 Ear Flushing
 Ear Cleaning
 Routine Toenail Trimming is part of the service today.
 Express Anal Glands
 FRONTLINE PLUS Application for Fleas
 Remove Warts / Skin Growth (Location: ______________________________)
EXTRACTION & OTHER PROCEDURES CONSENT / WAIVER
Many pets require sedation before a thorough examination can be completed. The condition of each
tooth must be evaluated before a decision is made as to the best course of treatment. Although no one
likes surprises, it sometimes is impossible to give an accurate estimate before sedation. From an
economic standpoint, it is much more economical to complete all needed dental procedures during the
initial visit and sedation rather than having to schedule another appointment with additional sedation
required. In an effort to satisfy your desires, please initial the appropriate option below:
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Please perform all medically necessary procedures & extractions that my pet needs at this time.
Please do nothing more than the requested dental cleaning procedure today.
Please call me after the doctor’s exam with an estimate if any additional procedures are needed.
Phone number where I can be reached today: ______________
PREFERRED TYPE MEDICATION TO ADMINISTER AT HOME: [ ] Tablets/Capsules [ ]
Liquids
OWNER RELEASE
You are to use all reasonable precaution against injury, escape, or death of my pet. I understand that all
sedation/anesthesia involves some minimal risk to my pet, but you will not be held liable in any manner
whatsoever or under any circumstances in connection therewith as it is thoroughly understood that I
assume all risks. I have read the foregoing and agree.
_________________________________________Date____________________________________
Signature (owner/agent