Dental Consent Form

When you need a veterinary clinic that’s more than just about animals and their health, look no further. South Texas Veterinary Clinic is here for all of your pet care needs!

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 361-358-8351 for a faster response.

Name *

Email *

Pet's Name *

Sex *

Color *

Date *

Procedure *

Dental
Extractions
Other

If other, please specify *

All patients undergoing an anesthetic procedure receive a pre-anesthetic examination by the doctor. They are monitored by pulse oximetry and kept on a heating blanket. We will place an IV catheter and administer fluids during the procedure. This will require us to shave a small area on one or both of the front legs. Each pet receives pain medication to provide immediate relief. Depending upon the severity of periodontal disease, we may send home additional pain medication for your pet. Antibiotic therapy may be necessary for treatment at home after surgery at an additional charge. In addition to the base charge of $148.50, which includes teeth cleaning and anesthetic, please make the following elections.

Basic Profile $42.50
General Health Profile $104.50
Coagulation Profile $50.15
Pain Management $25-$35

Perform whatever procedures are needed. I understand additional charges will accrue. *

I consent
I do not consent

Please call me at the number listed below. If for some reason I am unavailable when you call, please:

Perform whatever procedure are needed. I understand additional charges will accrue.
Perform necessary procedure and extractions up to $________. I understand that my pet may have to undergo another anesthetic episode to complete the dental treatment.
Do only what I have authorized. I understand that my pet may have to undergo another anesthetic episode to complete the dental treatment.

Perform necessary procedures and extractions up to

$25
$50
$75
$100
Other

If other, please specify

Has your pet had aspirin or prednisone(cortisone) within the past 7 days? *

Has your pet had anything to eat in the last 12 hours? *

List any medications your pet is currently taking and the last time they were administered:

Please mark the box of any additional services you would like performed:

Comprehensive Medical Exam
Rabies
DHLPP
Bordetella Oral
Heartworm Prevention
Proheart
Heartworm Test
FERCP
Leukemia
Fecal
Deworming
Nail Trim
Anal Gland Expression
Flea Prevention
Other

Heartworm Prevention dose: *

Flea Prevention dose: *

If other, please specify *

I accept full responsibility for the fees generated by such services, and I realize that they are due and payable at the time the animal is released from the hospital. *

I have read and understand.

Signature

Any and all contact numbers *

Ready for a visit?

South Texas Veterinary Clinic proudly delivers lifelong care for your animals in George West, Three Rivers, Refugio, Skidmore, Orange Grove, Goliad, Corpus Christi, Kenedy, Alice, and the surrounding areas. Call us for an appointment today.

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