Dental Consent Form

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Dental Consent Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Dental Consent Form Copy

Click here to Download the hard copy

Name *

First

Last

Email *

Pet's Name *

Home Phone Number *

Cell Number *

Work Number *

Procedure(s):

Please initial after each statement below:

I hereby consent that I am the owner/ agent of the above animal and have the authority to execute this consent. I further understand that during the performance of the foregoing procedure(s) unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s). Therefore, I hereby consent to and authorize the performance of such procedures(s) that are necessary and desirable in the exercise of the veterinarian’s professional judgement. I have also been advised as to the nature of the procedure(s) and the associated risks involved. I understand that results cannot be guaranteed *

I have read and understand

I understand that all dental procedures include a physical exam, pre-anesthetic bloodwork, IV catheter and anesthetic monitoring. The cost for these services is included in the cost of the dental procedure *

I have read and understand

Extractions

It can be difficult to predict if teeth need extraction when an animal is awake because tartar and movement interfere with the assessment. Severely diseased teeth can cause considerable pain and discomfort and are a source of infection for other organ systems (liver, kidney, lungs and heart). During the dental cleaning, the teeth are evaluated, and if found to be diseased they may require an extraction. I understand that extractions are not included in the cost of the dental cleaning *

I have read and understand

I authorize all medically necessary extractions be performed. *

Yes, I authorize.

I prefer to be called before any extractions are performed. Please be aware that if you cannot be reached by phone during your pet’s procedure no extractions will be performed and your pet will require a second anesthesia at a later date in order for those procedures to be performed. *

Yes, I agree.

Mass Removals

If your pet requires a mass removal today, please fill out attached form. Please be aware that the cost for mass removals is not included in the cost for the dental procedure

If your pet requires a mass removal today, please fill out attached form. Please be aware that the cost for mass removals is not included in the cost for the dental procedure

Please initial here if you would like a biopsy performed on your pet’s mass after removal. Please be aware there is an additional cost for this test

Please initial here if you would like a biopsy performed on your pet’s mass after removal. Please be aware there is an additional cost for this test

I understand that for the safety of the other pets in the clinic, if fleas are seen on my pet he/she will be treated and I will be financially responsible for the treatment cost. *

I have read and understand this authorization.

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Owner/Authorized Agent Signature *

Date *

Name

Dental Consent Form

Dental Consent Form

Dental Consent Form Copy

Extractions

Mass Removals

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