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Monday - Friday: 7:30am - 5:30pm
Saturday: 8:00am - 12:00pm
Sunday: CLOSED
(601) 856-3589
[email protected]
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Dental/Surgery Consent Form
Patient Information
Pet's Name
Client Name
First
Last
Phone Number
Email Address
I hereby authorize Ridgetowne Animal Clinic to perform the following procedure(s):
Spay
Neuter
Declaw
Mass removal
Sedate for exam
Dental
Other…
Enter other…
Dental - Please pick one of the following
Do whatever is needed to give my pet a healthy mouth, Including extracting problematic teeth. I am aware there will be fees that I am responsible for.
Contact me before doing anything beyond routine teeth cleaning
Acknowledgement
I understand that if my pet is in heat or pregnant there will be additional charges
I understand that if my pet is in heat or pregnant there will be additional charges
I understand that payment is due in full at the completion of service.
I understand that payment is due in full at the completion of service.
I understand that pain medication is required and it will cost $25-$50
I understand that pain medication is required and it will cost $25-$50
Did your pet get any medications today?
Yes
No
If yes, please list them
Additional Services
(All pets automatically receive a complimentary nail Trim)
We recommend a pre-anesthetic blood analysis to check the baseline parameters for your pet prior to an anesthetic procedure. Rest assured that advances in anesthesia have made routine procedures relatively safe, with a low rate of complications.
Pre-Anesthetic Bloodwork (CBC, Chemistry) $145
Yes
No
(HIGHLY recommend for all pets, REQUIRED for pets over 7 years old)
Permanent ID Microchipping $75.75
Yes
No
(1st-year enrollment in the National database included)
Nail Dremel $27
Yes
No
(DOGS ONLY- Files the nails down as close as possible and rounds them off)
Ear Cleaning $17
Yes
No
Anal Gland Expression $26
Yes
No
Other:
What email address would you prefer Ridgwtowne Animal Clinic to send discharge instructions for your pet following their procedure?
Please review and select one option
For every patient in our care, we need to know, in advance, what your wishes are if your pet stops breathing and/or his/her heart stops beating. We will make every attempt to contact you right away should your pet require resuscitative efforts. Additional expenses are incurred with the attempt to resuscitate the patient.
Resuscitation choice
*Required
Do not attempt Resuscitation (DNR): No cardiopulmonary rescission (CPR) efforts, only the administration of medication to help ease my pet's passing.
Cardiopulmonary Resuscitation (CPR): To attempt to restore normal heart function and breathing as deemed necessary by the doctor until I can be reached. Should my pet require cardiopulmonary resuscitation (CPR), I request that the doctor(s) may pursue suc
Signed (Owner or agent)
I, the above-signed owner, certify I have read and understand this authorization and consent that I am eighteen years of age or older. I understand that payment is due in full at the completion of service.
