Dental In-take Form | Oakview Vet Medical Center

We appreciate you taking the time to complete this form prior to your appointment. Appointments are only arranged at this time through speaking with a team member and submitting this form does not act to ‘book’ an appointment.

At this time we are surgery in-take for surgery admissions and discharges. Please call the office on arrival or, if before our hours, a team member will approach your car to get a contact number once you arrive.

In the last 10 days, have you or someone in your household, had symptoms or signs of illness?(Required)

Yes

Please note: Answering yes does NOT prohibit your pet from being seen if they are ill but allows us to put appropriate safety parameters in place for our team and doctors.

First Name(Required)

Last Name(Required)

Pets Name(Required)

What type of pet are they?(Required)

Dog

Cat

Other

Which type:

Scheduled Surgery or Procedure:(Required)

Microchip Implantation and Initial Registration(Required)

Yes, I want a microchip placed and registered (Additional fee applies)

No, I do not want a microchip placed in my pet at this time

No, I do not want a microchip placed, my pet already has one

Consent

I certify that I own the above-named pet, and I do hereby consent and authorize Oakview Veterinary Medical Center and its team to hospitalize and perform the agreed upon procedures or treatments as per the estimate as deemed advisable while my pet is under their care and supervision.

Hospitalization Agreement(Required)

I understand that the staff at Oakview Veterinary Medical Center will use reasonable precautions to assure my animal’s safety while in their care. I will not hold the staff or hospital responsible if the animal should injure itself, escape, fail to eat, become ill or die.

Hospitalization Requirements(Required)

I am aware that for the protection of my pet, other pets, and the staff at Oakview Veterinary Medical Center, pets are required to be current on vaccinations and free from parasites. If my pet does not have proof of current vaccines or is found to have parasites at the time of admittance the staff will provide treatment for them if necessary and I will be responsible for these charges. I have read, understand, and agree to the above

Anesthetic Consent(Required)

I understand anesthesia poses a risk to my pet, regardless of health, even though Oakview Veterinary Medical Center abides by strict standards of patient care and absolve Oakview Veterinary Medical Center of all liability arising of such a procedure. Anesthetics risks include, but are not limited to, respiratory arrest, cardiac arrest, esophageal stricture, vomiting, diarrhea, neurologic damage, and death. I understand the risks, and I consent to the administration of such anesthetics or tranquilizers as are necessary.

Waiver of Dental Procedure/Surgical Risks(Required)

I understand there are always potential risks when using anesthesia or performing a procedure on any animal. The potential for complications, during and after the procedure, depends on if more extensive dental work is required and the health of the animal. Risks may include but are not limited to, hemorrhage, failure to heal or incision failure, infection, loss of function, and scarring. The nature of the procedure/s was explained to me, and no guarantee has been made as to the results or cure.

I understand:(Required)

I understand if I or other person able to make decisions and authorize services cannot be reached within 10 (ten) minutes, my pet will be recovered. This may result in an additional procedure at my expense.

While in the care of Oakview Veterinary Medical Center, I authorize additional diagnostic tests and treatments to be performed on my pet if they are deemed necessary for the safety/immediate health of my pet. The Oakview staff will always try to contact me first, but I understand this medical care may be performed before I am able to be reached. I understand these additional urgent care measures may result in additional costs, regardless of the outcome for my pet. Please select if you do, or do not agree below.(Required)

I authorize emergency treatment as outlined above.

I do not authorize emergency treatment

Please provide a number at which you or an authorized person can be reached for any additional authorizations or emergency decisions:

The primary number will be texted at the start of procedure and when in recovery.

Primary Phone(Required)

Alternate Phone

For most effective anesthesia and surgical safety monitoring, please provide the following:

Time at which pet will no longer have to access to food prior to surgery:(Required)

Current medications and time/date of last dose to be administered before surgery:(Required)

I understand I will have the opportunity to ask and discuss any questions about anesthetic and surgical risks with the doctor prior to my pet's procedure.(Required)

Yes

Plan for conditions revealed during procedure:(Required)

The estimate provided only approximates the cost of this visit. It does not include any additional treatments that may be deemed necessary once examination and included treatments are underway. Frequently, thorough assessment and radiographs during dental cleanings reveal underlying conditions in the mouth area. You are responsible for all fees incurred during this visit, included or not, on this estimate.

Do what needs to be done, no phone call is required. This includes xrays, extractions, oral surgery, and other dental treatments not to exceed the following amount above the previously discussed estimate. If additional treatments would exceed that amount, the team will call you at the number below before proceeding (you must be available by phone)

Call you first with an estimate (you must be available by phone)

Wait on any treatments and discuss the condition/s at the time the pet is discharged to go home. I understand this may result in an additional procedure at my expense.

Limited amount(Required)

Consent(Required)

I have reviewed the estimate and understand I will be responsible for those fees, and any additional fees for services not known or unable to be predicted at the time estimate was created.

Signature(Required)

Please be assured that the health of your pet is our highest concern, and we will do everything possible to maintain that health. Your signature below indicates that you have reviewed and agree to these terms and estimate provided. All charges exceeding any down payment made are due and payable upon the patient’s discharge.

Name

This field is for validation purposes and should be left unchanged.