Dental Consent Form

First Name*:

Last Name*:

Email*:

Phone*:

Home Phone:

Pet Name*

Pet Species*

Cat

Dog

Other

Consent

Please initial the following to consent to dental treatment.

The following are included in our STANDARD DENTAL CLEANING.
- Hospitalization (CBC and Chemistry).
- Anesthesia (including pre-medications, induction agent, gas anesthesia, and monitoring).
- Intra-Oral dental radiographs.
- Ultrasonic enamel cleaning above and below the gum-line, rotary polish, and a pedicure.

Initial Below*

Fluid therapy: IV Catheter or subcutaneous fluids
Consent to shave for IV Fluid therapy helps to support kidney function and blood pressure during anesthesia, we include fluid administration either through an IV catheter or subcutaneously. IV catheter placement does leave a small shaved spot.

Initial Below*

Extent of Dental Services Desired

Should any unforeseen dental procedures be deemed necessary or desirable by the veterinarian's professional judgement, which of the options below do you consent to:*

I prefer that you proceed with all necessary dental procedures.

I prefer to be called before any additional procedures, other than emergencies. If I cannot be reached, I authorize you to proceed with all necessary dental procedures.

If I cannot be reached by phone, I do not authorize any unforeseen dental procedures. I understand this may result in needing to reschedule additional dentistry services at a later date.

Would you like your pet microchipped during their procedure(s)?*

Yes

Already Microchipped

I understand I may need to reschedule additional dentistry services at a later date if the doctor decides the procedure is not able to be performed in the scheduled time.
Initial Below*

Antibiotics and/or Pain Relief Medications: Will only be sent home if deemed necessary by the veterinarian and price varies. Is your pet currently on any medications?*

Yes

Agree to Terms: I understand that during the performance of the foregoing procedure(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or different procedure(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of veterinarian’s professional judgement. I also authorize the use of appropriate anesthetics and other medications and I understand the hospital support personnel will be employed as deemed necessary by the veterinarian. I have been advised as to the nature of the procedures or operations and the risks involved. I realize that results cannot be guaranteed. I understand that if my pet is kenneled overnight, there are no staff members present after hours.*

Consent

Extent of Dental Services Desired

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