Dental Procedure Consent Form

Name

First NameLast Name

Phone Number

Area CodePhone 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.

Other

Extractions/Dental Treatments:

Additional Services:

I authorize up to$* for treatment of medical issues discovered (unrelated to extractions or dental treatment) while my pet is under anesthesia if the veterinary team is unable to reach me. ($0-$1,000,000)

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.

Signature of owner or responsible agent:

Please verify that you are human