COHAT (Dental) Admit/Consent Form - Riverside Veterinary Hospital

Client Information

Owner's Name(Required)

First Last

Spouse's Name

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Spouse's Phone

Pet Information

Name(Required)

Species(Required)

Breed(Required)

Color(Required)

Age(Required)

Sex(Required)

Male

Male – neutered

Female

Female – spayed

Included in the COHAT (comprehensive oral health assessment and treatment) (0-50lbs: $495, 51-100lbs: $545)

Pre-Anesthetic Exam
Blood Profile: CBC,Basic Metabolic Panel, PCV/TP (if not recently done)
IV Catheter/Fluid Therapy
Anti-Emetic/Sedation/Pain Management Injection
Patient-specific Anesthetic Plan
Dental Radiographs
Dental Charting
Dental Cleaning/Polishing
Courtesy Nail Trim

Add On Procedures: (please tick)

Anal Gland Expression ($35)

Heartworm Test ($37)

4DX Heartworm Test ($54)

Vaccinations ($25 each, Rabies $35)

Ear Hair Removal ($30)

Ear Cleaning ($33)

Please list the vaccinations needed(Required)

Potential Additional Costs: PLEASE NOTE IF EXTRACTIONS, PRICE CAN DOUBLE TO TRIPLE THE BASE AMOUNT OF $495 or $545.

Surgical Extractions:

Incisors ($20 each)
Premolars/2 rooted teeth ($20 – $50 each)
Canines ($100 each)
Molar/Carnassial/3 rooted teeth ($50 – $100 each)

Local Anesthetic Blocks 1-4 sites ($80 total) Suture ($20)
Subgingival Antibiotic Treatment ($95)
Bone Graft ($95)
Gingival Flap ($25 – $250)
Additional Anesthesia beyond 1 hr ($56 per 15 min)
Constant Rate Infusion (Pain Medication IV Drip) $75 – 100
Soft Tissue Procedure ($25 – $150)
Additional Medications to go home (antibiotics/anti-inflammatory/pain) ($50 – $250)

*size and species of patient dependant*

Please select one:(Required)

Treat as needed – NO COST LIMIT

Treat as needed up to _____________________ dollar amount.

Dollar amount:(Required)

Owner's Intials(Required)

Please select one:(Required)

I understand that I will NOT be called during the anesthetic procedure unless the DVM deems it necessary.

I REQUIRE a call during the anesthetic procedure and hereby understand that if I am unreachable and do not respond within 5 minutes of the phone call, the DVM has my approval to continue or discontinue the procedure as they (DVM) see fit (including but not limited to: extractions, gingival surgery, oral mass removals, etc). You will be liable for all charges.

YOU MUST BE AVAILABLE TO TAKE CALL(S) FROM DOCTOR, REGARDLESS OF THE BOX CHOSEN ABOVE, WHILE YOUR PET IS HAVING PROCEDURE(S) DONE. WE MAY NEED TO GET FURTHER APPROVAL. IF YOU ARE NOT AVAILABLE BY PHONE, THEN YOU ARE CONSENTING TO FURTHER TREATMENT DEEMED NECESSARY/APPROPRIATE BY THE VETERINARIAN. (You will be liable for further charges)

As with any procedure requiring general and/or local anesthesia, there are certain risks that serious complications or even death may result. To minimize the risk of such occurrences, we mandate baseline bloodwork be performed in order to assure proper organ function, clotting ability, detect anemia or infection, baseline for future reference. The complete blood count (CBC) is a more sensitive indicator of disease than the physical exam. Additionally, white blood cells (WBCs) and platelets can change within hours due to acute infectious diseases. Abnormal glucose levels can increase the anesthetic risk and differ markedly between fasted and non-fasted samples, breeds, age, and sick and healthy patients. Evaluating electrolytes, hematocrit and total protein in fasted patients is essential for monitoring during anesthesia, minimizing the risk of arrhythmias and hypotension, and facilitating patient recovery.

As the owner of the above pet, No Patient, I certify that I am over the age of 18; and I authorize the staff of this hospital to perform the procedure(s) listed above, as well as those deemed necessary to treat life-threatening emergencies. As with all anesthetic, treatment, and/or surgical procedures, I understand there are risks inherent in these services. I acknowledge that staff members at this practice have explained the procedures to me, answered questions to my satisfaction, and cannot be held responsible for any unforeseeable results. Further, I understand that I am financially responsible for all costs incurred during this surgery, treatment, and hospitalization.

While I accept that all procedures will be performed to the best of the abilities of the staff at this facility, I understand that veterinary medicine is not an exact science and that no guarantees have been made regarding the outcome of this/these procedures. I have read and understand the nature of the above procedures and accept the specific terms and conditions set forth herein.

(Required)

I understand & consent to the above.

Should unexpected life-saving emergency care be required I would like the hospital staff to attempt the following life-saving measures (select one):(Required)

Closed Chest Resuscitation including drugs, CPR, defibrillation, and assisted breathing PLEASE BE ADVISED THIS MAY ADD A MINIMUM OF $250 (FOR FIRST 5-10 MINUTES) IN ADDITION TO THE PREVIOUS CHA RGES.

Do NOT attempt resuscitation

(Required)

I acknowledge that I am responsible for payment in full for the above procedures and treatments at the time my pet is discharged.

Signature(Required)

Date(Required)

MM slash DD slash YYYY

CAPTCHA

Client Information

Pet Information

Riverside Veterinary is Welcoming New Clients to Join our Family