Dental Procedure Consent Form

Name*

First Name Last Name

Phone Number*

Area Code Phone Number

Pet's Name*

We strive to amaze you with how clean your pet's mouth will look after the dental cleaning. In order to fully see the difference, please check the box below.*

I would like to have before and after pictures of my pet's mouth texted to me. Sent to phone number aboveI would like to have before and after pictures of my pet's mouth texted to me. If different enter phone number belowI do NOT want before and after pictures texted to me.

Extractions/Dental Treatments:*

I authorize all medically necessary extractions/dental treatments be performed. I accept that additional charges will apply.I prefer to be called before any extractions/dental treatments are performed.If I cannot be contacted by phone, I do not authorize any extractions/dental treatments to be performed. *Please be aware that if you decline any needed procedures, your pet would need a second anesthesia at another time in order for those procedures to be performed.*

Additional Services:*

I would like my pet to have a complimentary pedicure while under anesthesiaI would like my pet to have anal sacs expressed (additional cost of $27.05) while under anesthesiaI would like my pet to receive a Home Again Microchip (additional cost of $60.52, including registration) while under anesthesiaNone

I understand that my pet is here for a procedure that requires anesthesia. In order for anesthesia to be as safe as possible, I understand that my pet must have healthy blood-work results within the last 30 days. I understand that if my pet has not had blood-work performed in the last 30 days, pre-anesthesia blood-work will be done today. I understand that during the performance of the foregoing procedures, unforeseen conditions may be revealed that require additional treatments that those specifically listed above. If such procedures are necessary in the veterinarian’s professional judgment, I consent to the performance of these procedures as well. I understand that all patients will be examined for flea and/or tick infestation before the dental procedure, and that if needed my pet will be treated at my expense. I have also been advised as the nature of the procedures and the risks involved. I realize that results cannot be guaranteed. I have read and understand this authorization and consent.*

I understand and approve anesthesia for my petI do not approve anesthesia for my pet

Signature of owner or responsible agent:*

Clear

Please verify that you are human*