<p> (770) 483-7225</p><p>DENTAL ANESTHESIA RELEASE</p><p>Pet’s Name: ______Owner’s Name: ______</p><p>Phone Number: (____) ______</p><p>Pre-Anesthetic Blood Work………………..…….For Animal less than 8 years old $70: ( ) Accept ( ) Decline To help reduce the risks associated with general anesthesia, I accept the pre-anesthetic blood test at an additional cost of $70 we highly recommend the Pre-Anesthesia blood test. This test will evaluate the health of major organs (liver and For Animal greater than 8 years old $85: ( ) Accept ( ) Decline kidneys) which process the anesthesia from the body. I accept the pre-anesthetic blood test at an additional cost of $85</p><p>Anesthetics (please check one) Sevoflo is recommended for pets over 8 years of age ………………………………Isoflurane $105 ( ) Sevoflo $130-150 ( ) and/or high risk cases. *Additional charges for procedures **Varies by weight** lasting more than 60 minutes.*</p><p>Doxirobe Your pet may have diseased teeth that may be saved by………………… Accept ( ) Decline ( ) $60 using this product. It is a brand of doxycycline gel that is used at the base of the tooth aiding the root to bond back to the gums. </p><p>Premium Dental Upgrade………………………………Accept ( ) Decline ( ) $30 Oravet Barrier Sealant is applied just after cleaning your pet’s teeth. Used on freshly scaled teeth it will help reduce plaque and tartar formation by preventing bacteria from attaching to the surface of your pet’s teeth.</p><p>Extractions The prices for extracting teeth that need be removed vary depending……………. Initial ( ) on how difficult and how much time it takes to remove them. $22/Routine $55/Complicated ***Prior to a dental procedure it is difficult to give an accurate quote. When the dental tartar is removed, we may find that the tooth is diseased. Again, the extraction can vary in complexity and time. We will make every attempt to give you an estimate, if further costs arise we will make every attempt to contact you. ***</p><p>Nail Trim $2 Anal Gland Expression $2 Ear Cleaning $2</p><p>Post-Surgical Pain Management Cats………………………..…………. $ 42 Dogs 31-89 lbs……………………………….…. $ 52 Dogs 30 lbs. and under……………. $ 48 Dogs 90 lbs. and over…………………….……. $ 62</p><p>I understand that I assume the financial responsibility for all approved services performed, and that payment is due when the pet leaves the hospital. There will be additional charges for medications and/or supplies dispensed by the doctor. *Flea medication will be administered if fleas are noticed on the pet, for an additional charge.*</p><p>Signature of Owner/Agent: ______Date: ______</p>