Dental Procedure & Pain Management Consent Form Dental Procedure & Pain Management Consent Form "*" indicates required fields Pet's Name* Date* MM slash DD slash YYYY Please check ONE of the following:* Perform any extractions necessary Call me first, but if you cannot reach me by telephone, you may proceed with any procedure(s) deemed necessary Do nothing unless you reach me by telephone. I understand that you will wake my pet up without doing even the simplest of any additional procedure(s). I also understand that should I agree to the recommended procedure(s) at a later date, there will additional charges for anesthesia and procedure(s) I understand the estimated cost for a dental procedure is an estimate and my final bill may be more or less than the total estimate given to me. Pain Management Package We at Middletown Veterinary Hospital strongly believe in the importance of pain management before, during and after dental procedures if extractions are necessary. The package includes a pain injection and take home products for you to administer at home. Which type of package do you want to avail?* Canine Pain Management Package - includes an injection before surgery and appropriate medication for at home use. Feline Pain Management Package - includes an injection before surgery and appropriate medication for at home use For Dogs under 25lbs - $26 25-50lbs - $35 50-75lbs - $41 76-100lbs - 46 over 100lbs - $50 For Cats All Cats - $29 accept / decline* I ACCEPT the pain management package for my pet I DECLINE the pain management package for my pet Between 9am and 4pm I can be reached at:*Signature*Date* MM slash DD slash YYYY
