Sometimes the damage from periodontal disease cannot be determined until the teeth are cleaned. We believe teeth are important and we do everything possible to save teeth. If a tooth or gums require more advanced care that we can provide, we recommend Dr. Visser at Aid Animal Clinic for further care. We will notify you if more advanced care is needed.

We work to save all teeth. If a tooth, however, is going to be a chronic source of pain and/or infection, the chances are the tooth will be extracted. Extraction is always a last resort. The doctor will examine each tooth after they are cleaned and polished to determine if further therapy is needed. Antibiotics and post-op pain medication will be dispensed as determined by the doctor.

Name*

First Last

Pet Name*

Phone*

Email*

Text, phone call or email preferred?*

Phone call
Text
Email

What procedure is being performed?*

Have you noticed any behavioral or medical changes in your pet since we last saw them?

Since we last saw your pet, have you started them on any new medications or supplements?

Yes
No

If yes, please list the medication/ supplement below as well as the dose and how often you are giving it.

Since we last saw your pet, have you started them on a new diet or have they started eating new treats?

Yes
No

Any additional services or issues that need to be addressed?

What can we do to make your pet’s stay with us even better today?

Do you authorize anyone else to pick up your pet?*

*

I understand that prepayment of services is required unless otherwise discussed at admittance.

Do you grant 43rd Ave Animal Hospital to post your pet’s picture, story and medical information on social media/or our website?*

Yes
No

I, the undersigned owner or authorized agent of the admitted patient, hereby authorize admitting Veterinarian and the designated associates/assistants to administer such treatment as is necessary to perform the forementioned procedures. I also consent to the administration of such anesthetics as are necessary. I authorize additional treatment such as emergency procedures as might be necessary without my approval.*

(initials)

I further understand that no guarantee of successful treatment is made or implied.*

(initials)

I also assume financial responsibility for all charges incurred to patient and agree to pay all charges.*

(initials)

I hereby authorize that I have read and fully understand this authorization for any medical and/or surgical treatment that I considered, as well as it’s advantages and complications if any.*

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