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Dental Surgery Drop-Off Questionnaire
APPOINTMENT
Dental Surgery Drop-Off Questionnaire
Please complete the form below prior to your appointment.
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Owner Name
*
First
Last
Cat’s name
*
Your cat is scheduled to have a comprehensive oral assessment and treatment under anesthesia. As part of this procedure, your cat will have it’s teeth thoroughly cleaned (scaled and polished), examined and probed. Full mouth dental radiographs will also be performed and reviewed.
Has your cat been vomiting?
*
Yes
No
Has your cat had diarrhea?
*
Yes
No
Has your cat been coughing?
*
Yes
No
Has your cat been sneezing?
*
Yes
No
Any change in appetite?
*
Yes
No
Any change in behavior?
*
Yes
No
Additional services requested:
Nail trim – no cost
*
Yes
No
Ear Cleaning ($22.75)
*
Yes
No
Hygiene Trim ($27.00)
*
Yes
No
Microchip Implantation ($38.00)
*
Yes
No
I acknowledge that I have received an estimate for my cat’s anticipated dental care.
*
Yes
No
Do you have any questions or concerns that you would like addressed prior to your cat’s procedure today?
*
Yes
No
Please explain your questions or concerns
I hereby authorize The Cat Doctor of Monroe and Dr. Kimberly Scutchfield to use sedation and/or general anesthesia on my pet. I understand that sedation and anesthesia pose a risk to my pet, regardless of health status. In the event of unforeseen complications, I give permission for the doctors and staff to take reasonable measures in treating my pet and accept all charges that are incurred as a result of such action. As the owner or appointed caregiver, I understand that by signing below, I agree to pay for all charges +/-15% of the fees for my pet’s procedure and will pay the balance in full upon discharge of my pet. The sedation and/or anesthesia and relevant procedure costs have been fully explained to me to my satisfaction.
I understand that many oral lesions may not be evident until my cat is under anesthesia, he/she has had an oral examination, and dental radiographs have been evaluated. Should additional disease be found, I authorize Dr. Scutchfield to proceed with treatment she deems appropriate for my cat. This may include dental extraction(s) at a base surgical cost of $175 and an additional cost of $78 per tooth extracted. I understand that I am responsible for paying any additional costs incurred and accept the risks involved with oral surgery (including - but not limited to - pain, infection and bleeding).
I acknowledge that I am leaving my cat under the care of the staff at The Cat Doctor of Monroe. If my cat has dental extractions, I understand that my cat will need to stay overnight for comfort evaluation in the morning. I understand that this facility is not staffed 24 hours per day and is not staffed on the weekends or holidays and that there could be complications which may become serious if not detected right away and may result in further injury, illness or death to my cat. I understand that I have the right to transfer my cat to the emergency center for 24 hour care at any time. I also understand that if an emergency does arise where I cannot be reached, the doctors and staff of The Cat Doctor of Monroe have the authority to treat my cat as deemed necessary to stabilize him/her.
If there is evidence of fleas (live fleas, flea feces) we will administer a flea treatment to your cat and you will be responsible for the cost of the medication.
Payment is expected at the time of service. How will you be paying today?
*
Cash
Credit/Debit
Check
Care Credit - minimum $200 transaction
Owner signature:
*
Clear Signature
Date
*
Please provide us with the best phone numbers to reach you today:
1. Phone Number
*
2. Phone Number
Preferred method of contact (you can select more than one)
*
Text
Phone Call
Email
Email
*
Email
Submit
