Dental Form | Northfield Veterinary Hospital

Thank you for working with Northfield Veterinary Hospital in Denver! To save time, please fill out our Veterinary Dental Form below. For additional information, please contact our office directly by calling (303) 375-1735.

Pet's Name*

Breed*

Sex*

Female

Male

Age*

Procedure*

We also offer text messaging updates for the procedure, would this be a service that you would like to receive?*

Yes

Is your pet presently on medication(s) including aspirin?*

Yes

ANESTHESIA AND SURGERY CONSENT FORM

Owner responsibility:

I understand that home care administered by myself or a designated caretaker may be required to achieve best overall success. It is my responsibility to notify Northfield Veterinary Hospital before altering the doctor’s recommendations. I understand that changes, supplementation, or alteration of any prescriptions may possibly result in an unfavorable or detrimental side effect with medical complications.
• I agree to make myself available by telephone during the approximate time interval of 9AM to 3PM.
• Home care instructions will be provided at the time of the pet’s discharge.
• I understand that payment for services rendered will be due in full at the time of cv pet’s release.

Hospital and Procedural Information:

• Anesthesia: Pre-surgical blood tests and physical examination will enable us to assess and minimize the risk of anesthesia to your pet.
• Monitoring: To minimize anesthetic risk, we monitor the heart rate, blood pressure, EKG, capnography, respiration rates, temperature, and pulse oximetry.
• Catheterization: For sterility, hair will be shaved over a vein on the leg so that an intravenous catheter (I.V.) can be placed. Blood pressure may lower during anesthetic procedures and fluid therapy aids in supporting your pet’s internal organ systems. It also allows immediate access to the vascular system in case of an emergency.
• Pain Management may be necessary in some procedures. The doctors will administer pain medications accordingly to your pet’s needs, which can be an additional fee ranging from $35.00 to $55.00
• Antibiotics are an additional fee ranging from $30.00 to $80.00 and may be prescribed by the doctor for your pet’s needs.
• Pre-Op Blood work: Blood work is required for any patient going under anesthesia to ensure that kidney and liver function is adequate to process and eliminate anesthesia.

Patient Information

Did your pet eat this morning?*

Yes

Has your pet had any vomiting, diarrhea or coughing within 20 days?*

Yes

Has your pet ever had seizures?*

Yes

Is your pet allergic to any medications, anesthetics, food, or vaccince?*

Yes

Extractions:

It can be difficult to predict if teeth need extraction when an animal is awake because tartar and movement interfere with the assessment. Severely diseased teeth can cause considerable pain and discomfort and are a source of infections for other organ systems (liver, kidney, lungs, and heart. During the dental cleaning, the teeth are evaluated, and if found to be diseased they may require an extraction or referral to a dental specialist for repair.

The cost of extractions varies depending on the difficulty and can range from $29.00s- $240.00 per tooth. We will always call if we note an area of concern, but if for some reason we cannot reach you please indicate how you would like us to proceed.*

I authorize all medically necessary extractions be performed.

I authorize all medically necessary extractions up to extraction cost only.

If, I cannot be contacted by phone, I do not authorize any extractions to be performed. *Please be aware that if you decline any needed procedures at this time, your pet would need a second anesthesia at another time in order for those procedures to be performed.

I would prefer to seek out a dental specialist for further treatment such as root canals, fillings, and orthodontics

Data Mars Microchipping

Home Again Microchipping is an advanced pet identification and retrieval system. This permanent microchip, with a unique identification code, is implanted under the skin between the shoulders of the pet. The microchip is about the size of a grain of rice and you cannot see the microchip after it is implanted in your pet.

The microchip, implant, and membership fee is $50.00**

Yes, I authorize the veterinarian to implant my pet today with a Data Mars microchip

No, I am declining the implant of the Data Mars Microchip

Authorization*

I have read and fully understand this surgery and anesthesia consent form.

I authorize anesthesia and surgery for my pet, as described above. The nature and risks of this procedure have been explained to me. I understand that some risks always exist with anesthesia, dentistry and/or surgery, and I am encouraged to discuss any concerns I have about those risks with the hospital’s medical staff before the procedure(s) is/are initiated.
Additionally, I authorize Northfield Veterinary Hospital to perform any diagnostic, medical treatment, dentistry, or surgical procedure as deemed necessary for any unforeseen medical or surgical complications if one should arise.
While Northfield Veterinary Hospital provides the highest quality of anesthesia monitoring, dentistry, and surgical services, I completely understand the possibility of unforeseen complications that may occur during any associated anesthetic, dentistry or surgical procedure. I fully acknowledge and understand these medical risks.
I recognize that the veterinarians and hospital staff will do all that is necessary to minimize such risks. I will hold harmless Northfield Veterinary Hospital, the veterinarians, or any hospital staff member liable for any complications that may or should arise in my pet’s medical treatment and care.
I understand that the hospital is not liable for any lost or damaged personal property (leashes, collars, etc.) that are left in the hospital. If I neglect to pick up my pet within 5 days of the date below and do not notify you within that time frame you may assume that my pet is abandoned.
No warranty or guarantee has been offered or given to me as to the results or cure afforded by these treatments or procedures.

Signature*