Dental Consent

Dental Consent

Please read each section in it's entirety and ask a staff member if you have questions or concerns regarding consent for treatment. Thank you!
Date of Appointment

Month Day Year
Date
Client’s Name *

First Name Last Name
Pet’s Name *
Phone Number *
Please enter a phone number you may be reached at today.
Would you prefer text or phone call communications while your pet is with us?

Texts Phone Calls
I am the owner or authorized agent for the animal above, am over 18 years of age, and I have the authority to sign this consent. *

Yes No
I understand that there are certain risks and complications associated with sedation, anesthesia, and/or any operation/procedure. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before the procedure is initiated. *

Yes No
I understand that the use of appropriate anesthesia and pain relief medication as needed before, during or after the procedure. I understand that there are risks associated with the use of any medication. *

Yes No
Financial Obligation Approval: The nature of these operations or procedures has been explained to me and I understand what will be done. I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. I have been encouraged and given the opportunity to discuss any questions I may have regarding my pet's medical care and my questions have been answered to my satisfaction. I accept that my financial obligations remain regardless of the outcome. *

Yes No
Pre-surgical Bloodwork Approval: We encourage all patients undergoing any procedure involving anesthesia to have pre-anesthetic bloodwork. This bloodwork gives the doctors additional information regarding your pet's ability to metabolize and safely recover from anesthesia. This bloodwork also allows the doctors to determine if you pet has an underlying condition that may inhibit the ability to recover safely. If I decline this bloodwork, I understand that the doctors may not be able to intervene appropriately should my pet have an adverse anesthetic event. The cost for pre-anesthetic bloodwork is $110.00. *

Accept Decline
CPR Approval: Although adverse reactions to anesthesia are rare, in the event that your pet should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for CPR to be initiated until you can be contacted and notified of your pet’s status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not available to be contacted immediately, resuscitation efforts will continue to be performed at the doctor's discretion. *

Accept Decline
Extraction Disclaimer: I understand that with any extraction, there is the possibility that a fragment of a tooth root could be left behind. It is also possible in severe dental disease that a jaw fracture could occur when a tooth is extracted. I will not hold the doctor liable in the event that this occurs and will take financial responsibility for extra costs incurred for treatment of either condition. *

Yes No
Extraction Approval: If my pet needs to have extractions or other necessary dental procedures performed, I wish to have the doctor proceed without being called first. If I decline, I understand that if I do not answer the doctor’s phone call within 10 minutes, that my pet will be woken up and the necessary procedures will have to be performed at a later date with additional cost. *

Accept Decline
Check additional service(s) you would like performed today: *

Vaccinations-prices vary Nail trim-$10.00 Anal gland expression-$15.00 Ear cleaning-$12.00 Cold Laser Therapy for Extractions-$10.00
Please list any additional procedures you would like performed that are not listed above.
Signature

Clear
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform