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

Prairie State Veterinary Clinic Dental Worksheet

 

(Use this form for estimates and procedures)

Pet: ____________________________ Date:______________________ 

                    Optional Testing:

[   ] BLOODWORK (CBC AND CHEMISTRY PANEL) $91.48 (.DTL18) Initial:________
[   ] ELECTROCARDIOGRAM $77.01 (L252) Initial:________
[   ] CHEST RADIOGRAPH $91.46 (R101B) Initial:________

 

GENERAL ANESTHESIA (INCLUDES):                  $148.62  (.DTL2)

Dental suite use

Intravenous catheter setup and fluids: Lactated Ringers or Normosol.

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 (DTL3)

                                                   

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 =

____________.

Nerve Block(s):                                                                                                                       .

Gum surgery:                              Yes / No ___________________________________________.

Radiographs:       First @ 36.85        Each Additional @ 22.24 

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:____________________________________ .