Dental Check-In Form

Pet:

Owner:

Date:

Contact Phone #

Did your pet eat this morning?

Yes
No

Is your pet allergic to any medications?

Yes
No

Has your pet been ill or injured in the last 30 day?

Yes
No

Does your pet have a history of seizures or previous problems with anesthesia?

Yes
No

If your pet’s vaccinations are not current, would you like us to update them today?

Yes
No

Please list any and all medications /supplements your pet is currently taking;

Please select any elective procedures you would like us to do for your pet today:

If Other:

*Once your pet’s teeth are clean, we then check and assess each tooth for any problems such as; fractures, infection, cavities, irreversible tooth decay, etc. If any problems are found where diagnostics and treatments will be the best course of action, we will make the appropriate recommendations to assure your pet the best possible care now and for the future.

May we take Dental X-Rays if found necessary?

Yes
Call First

May we extract diseased teeth if found necessary?

Yes
Call First

May we treat diseased teeth if found necessary?

Yes
Call First

*In the event we call and you are unreachable by phone, is there anyone else charged with making decisions on your behalf?

*Name & Number

Anesthesia Release

Yes
No

For enhanced protection of our patients we recommend a Pre-Surgical Blood Screen of all pets prior to the administration of anesthetics. I understand that there is an additional charge for this and if I refuse this service, I am therefore responsible for any risks or complications that may arise from the surgical procedure being performed today. ****I would like my pet to undergo the aforementioned Pre-surgical Blood Screening. Additional cost of $55

Initial Here:

I understand that the doctors and staff at Valley View Veterinary Hospital will use all reasonable precautions against injury, escape, or death of my pet. I understand that anesthesia and surgery always involve some risk to my pet and I agree that Dr. King or Dr. Hartman and their staff will not be held responsible in connection to these procedures. In the event complications arise and I can not be immediately contacted at the phone numbers provided, I give full consent to Dr. King and/or Dr. Hartman and their staff to perform whatever actions reasonable, necessary and in the best interest of my pet. I have read and agree to the above information.

Signature

Location

Contact

Business Hours