Dental Consent Form

Thank you for choosing Lifetime Pet Center of New Richmond for your pet’s dental care. To confirm your appointment and help us understand your pet’s health requirements, please complete our online form.

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How to Complete the Form

Please fill out all required fields as accurately as possible. Providing detailed information allows us to tailor your pet’s dental care to their individual needs.

Submit Your Consent Form

Use the form below to submit your pet’s dental information and consent. Be sure to include all details so we can provide the best possible care.

Today's Date(Required)

MM slash DD slash YYYY

Owner's Name(Required)

First Last

Best Contact Number for Today(Required)

Secondary Contact Number

Do you prefer a phone call or text message in the event we have questions during the procedure and for Dr. Miller's post-procedure update?(Required)

Phone Call

Text Message

No Preference

Patient Name(Required)

Species(Required)

Dog

Cat

Age(Required)

Sex(Required)

Male Intact

Male Neutered

Female Intact

Female Spayed

Does your pet have any known allergies?(Required)

Yes

If your pet has known allergies please list them below (food, medications, anesthesia, vaccines, etc.).(Required)

Please confirm your pet has not had any food or snacks since before midnight last night (the night before the procedure, a very small amount of water is ok).(Required)

My pet has not had any food or snacks.

My pet ate this morning.

Is your pet doing well at home or do you have any concerns we should be aware of before the procedure today? (Select all that apply)(Required)

My pet is doing well and I do not have any concerns.

My pet has experienced vomiting/diarrhea/coughing/sneezing (any or all) within the last several days.

My pet has been lethargic/appetite is off/ water intake is off (any or all) within the last several days.

My pet is experiencing other symptoms not listed above that I would like Dr. Miller to address today.

Please list your pet's current medications and supplements below, their dosages, the frequency you give them, and when they received their last dose. If they are not on any current medications please type in "N/A" or "no medications" below.(Required)

I hereby consent and authorize Lifetime Pet Center of New Richmond to prescribe for, treat, or operate upon my pet (listed above). I have been advised of the risks associated with treatments and/or surgery. It is thoroughly understood that I assume all risks and will take responsibility for payment of services rendered. Please sign your initials in the space below to acknowledge the above.(Required)

The Lifetime Pet Center of New Richmond will use all reasonable precautions against injury, theft, escape, or destruction of the animal(s) listed above, but will not be held responsible in any manner whatsoever on account of the care, treatment, or safekeeping of the animal(s) above described, as long as acceptable standards of veterinary medicine have been followed. Please sign your initials in the space below to acknowledge the above.(Required)

It is also noted that my pet will be vaccinated if medically neccessary or if recommended by the prescribing doctor in order to protect the safety of my pet and the staff handling my pet. Please note that rabies vaccination is required by county law. In addition, if my pet is found to have fleas or other parasites while in the hospital, s/he will be treated accordingly as seen fit by the doctor and staff. Please notify us if your pet has any allergies or drug sensitivities. Please sign your initials in the space below to acknowledge the above.(Required)

By signing below, I confirm that I have read and understand the information above.(Required)

Your pet is undergoing a dental assessment and prophylaxis (cleaning) today. We may discover additional conditions while your pet is with us, which could incur additional charges. Some aspects of your pet's oral health can only be assessed while your pet is under anesthesia and after full-mouth dental X-rays have been performed. These may include:

Proper visualization of the teeth, especially the back teeth.
Many periodontal problems that can only be detected by probing under the gumline.
Dental tartar that can hide underlying cavities, fractures, and loose teeth.
Disease or bone loss above the gumline indicating teeth may need to be extracted or treated with a periodontal treatment.

Please indicate how you would like us to handle these situations should they occur:(Required)

Do the procedure regardless of cost.

Call with an estimate for additional charges. If we are unable to reach you we may perform the procedure.

Call with an estimate for additional charges. If we are unable to reach you we may not perform the procedure.

Other

If other, please specify:(Required)

Your pet is scheduled for general anesthesia/ or sedation today. We recommend a pre-anesthetic blood profile regardless of age to ensure your pet is healthy enough to undergo this procedure. We process all blood samples in-hospital and will have results in under 10 minutes. These tests resemble those that your own doctor would require before you underwent an anesthetic procedure. In addition, these test results will serve as reference values should your pet become ill in the future.

Description of tests:

Comprehensive Profile & Complete Blood Count (CBC)

A comprehensive profile is recommended for all pets that have not had blood work done in the last year. This profile is REQUIRED for all pets that are 7 years of age or older or if they are ill. For older pets it can be done up to two months prior to the procedure. (It includes electrolyte levels, liver and kidney function, blood glucose, white and red blood cell count, and more.)

Thyroid/ Cholesterol Panel

This test may be recommended for your pet depending on other health concerns. We will notify you if the doctor recommends this test.

Species Specific Testing:

FeLV/FIV Combo Test (Cats Only)

This test is recommended for all cats that have not been tested previously, especially kittens and previously stray cats. Both FeLV and FIV are highly communicable diseases that decrease a cat's ability to fight infections and illness.

Blood Parasite Screen (Dogs Only)

This test is REQUIRED for all dogs not currently on heartworm prevention before undergoing anesthesia or sedation. (It includes heartworm, Lyme disease, Ehrlichia canis, & Anaplasmosis.)

Please select which panels you would like your pet to have done today prior to the procedure. (Note: some may be required, as described above).

Please select which panels you would like your pet to have done today prior to the procedure. (Note: some may be required, as described above).(Required)

FeLV/FIV Combo Test (Cats Only) ($60.70 or $40.70 w/ other bloodwork)

Blood Parasite Screen (Dogs Only) ($55.42 or $45.28 w/ other bloodwork)

Comprehensive Profile & CBC ($113.66)

Thyroid/ Cholesterol Panel ($72.56, or $52.56 w/ other blood work)

None (Please note you may not be able to decline bloodwork and it may be required based on your pet's age and general health status)

If your pet has had blood work done with normal results within the last two months, the blood work for this procedure may be waived. If your pet is 6 years of age or under, it may also be waived.

By declining pre-anesthetic blood work for your pet you understand and assume all risks involved related to not performing the recommended testing before an anesthetic procedure. Pets can have underlying health concerns that do not show obvious symptoms, which can lead to anesthetic complications, and in some instances, death.

By signing below, I agree:(Required)

I am declining the recommended bloodwork for my pet, regardless of risk.

I have authorized the bloodwork above.

Your pet may need additional pain control if extractions or other surgical procedures are performed. If at-home pain medication is required, please indicate your product preference below.(Required)

Dogs- Galliprant Chewable Tablets- 1 tablet given orally once daily for three days after the procedure. $18.56 to $29.30

Dogs- Loxicom Oral Liquid- 1 pre-dosed syringe given orally once daily for three days after the procedure. $23.10

Cats- Onsior Chewable Tablets- given at home orally for three days after the procedure. $31.34

Cats- Zorbium Topical Solution- applied in-house by staff before the procedure and provides four days of pain control at home. $49.40 to $60.58

Please note: bloodwork may be required for your pet.

Would you like an estimate for today's procedure (if you haven't already been provided one)?(Required)

Yes

I already have an estimate.

Please provide an email address if you would like an estimate.(Required)

By signing below, you acknowledge that the estimate (if requested) for the procedure is not a guaranteed price for services. Unforeseen circumstances may arise that could increase the cost of the procedure. We will make a reasonable effort to inform you and obtain consent for any additional services before proceeding, except in the case of a life-saving emergency. If you have any questions or concerns, please speak with a staff member before your pet's procedure.

Signature(Required)

Contact Us

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Contact

Call Or Text: (513) 553-9954
Email: lifetimepetcenters@gmail.com

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Location

1044-A Old US 52
New Richmond, OH 45157

Our veterinary hospital is conveniently located to serve families in New Richmond, Greater Cincinnati, and nearby communities, including Moscow, Amelia, Bethel, Felicity, and Withamsville.

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Hours

Monday & Tuesday: 8:00 AM – 5:00 PM
Wednesday: 8:00 AM – 3:00 PM
Thursday & Friday: 7:30 AM – 5:00 PM
Saturday: 8:00 AM – 1:00 PM
Sunday: Closed

Have a Question?

Please complete our online form and a member of our team will get back to you as quickly as possible.

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