Prairie State Veterinary Clinic
100 Ravinia Place
Orland Park, IL 60462     708-349-3331

 

A Veterinary Family Practice Clinic Dedicated To Exceptional Primary Care.

Prairie State Veterinary Clinic

100 Ravinia Place
Orland Park, IL 60462

(708)349-3331

flemingvet.com

Dental Worksheet

(Use this form for estimates and procedures)

Pet: ______________________ Date:______________________ 

Fees as of August 2017:

                    Optional Testing:

[   ] BLOODWORK (CBC AND CHEMISTRY PANEL) $91.40 Initial:________
[   ] ELECTROCARDIOGRAM $77.01 Initial:________
[   ] CHEST RADIOGRAPH $91.46 Initial:________

 

GENERAL ANESTHESIA INCLUDES:                  ($148.62) 

Kidney test (azostik) even if full bloodwork declined

Dental suite use

Intravenous catheter setup and fluids

Intravenous induction of anesthesia

Inhalation anesthesia

Pulse-oximetry monitoring

Post-procedure monitoring and nursing care

Heated blanketed cage

Disposables and medical waste disposal

 

 

ULTRASONIC SCALING, POLISHING AND FLORIDE APPLICATION:     86.23 (.DTL2)

 


                                                          

EXTRACTIONS: Single-rooted tooth #_______ @ 16.93 = ____________.  
  Double-rooted tooth #_______ @ 24.27 = ____________.
  Triple-rooted tooth #_______ @ 30.58 = ____________.
  Canine or Upper 4th Premolar #_______ @ 15.00 – 95.00 = ____________.

     Internet readers note: If any tooth is loose and easily extracted we hardly ever, if ever, charge the fees noted above. We're easy.

Radiographs:       First @ 36.85        Each Additional @ 22.24

Gum surgery:                              Yes / No ___________________________________________.

 

Oral tumor surgical excision:     ___________________           Histopathology: Yes / No

 

Antibiotic Injection: Yes / No     Ceph [   ]      Clin   [   ]        Enro   [   ]      Amp [   ]        (18.20)          

 

Pain injection: Yes / No  Butorphanol* Hydromorphone* Morphine* Carprofen  (24.47) * DEA LOG

Home Antibiotics: Yes / No           Rx:___________________________ .

 

Home Pain Meds: Yes / No           Rx:____________________________ .

 

Other Services Performed:____________________________________ .

 

Pre-op testing as above is optional. If bloodwork is declined a kidney test is still performed as part of the anesthetic package. All pets receive an antibiotic injection. Home antibiotics, pain injections and go-home pain meds are only for pets who have had an extraction(s).