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
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Month
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Day
Year
Date
Client’s Name
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First Name
Last Name
Pet’s Name
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Phone Number
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Please enter a phone number you may be reached at today.
Format: (000) 000-0000.
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.
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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.
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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.
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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.
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Yes
No
Pre-surgical Bloodwork Acknowledgement: 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 your 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.
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My pet has already had blood work performed in the last 30 days.
I decline to have presurgical bloodwork for my pet and understand the risks with anesthesia.
To allow for optimal treatment, all hospitalized patients are assigned a CPR or DNR code regardless of health, age, or elected procedure. These codes enable the medical team of Sweetbriar Veterinary Clinic to carry out your wishes if it should become necessary during or following an emergency or anesthetic procedure. Should my pet arrest (stops breathing or heart stops) while at Sweetbriar Veterinary Clinic, I authorize one of the following options. Please select only one of the following:
CPR (Cardiopulmonary Resuscitation): By choosing CPR, I authorize basic life saving efforts and procedures deemed to be appropriate by the medical team of Sweetbriar Veterinary Clinic in the event that my pet should experience cardiopulmonary and/or respiratory arrest. This involves but is not limited to chest compressions, intubation, oxygen therapy, intravenous fluids, and medications. CPR does not resolve any underlying diseases and the outcome is uncertain. Animals that have survived cardiopulmonary and/or respiratory arrest and have been successfully resuscitated are deemed critical and unstable. I understand that Sweetbriar Veterinary Clinic will not be held responsible for any injuries that may occur from the actions associated with cardiopulmonary resuscitation.Should the Sweetbriar Veterinary Clinic team be unable to reach me within 10 minutes after the initiation of CPR procedures, and after the veterinarian determines that further resuscitation efforts are no longer warranted, CPR procedures will cease.Having requested such emergency procedures, I agree to be held financially responsible for all services provided to my pet while the medical team of Sweetbriar Veterinary Clinic pursue treatment, regardless of my pet’s recovery or survival.
DNR (Do Not Resuscitate): By choosing DNR, I do not authorize further medical intervention should my pet suffer from cardiopulmonary and/or respiratory arrest. No life saving measures will be attempted and my pet will pass away.
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.
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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.
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Accept
Decline
Check additional service(s) you would like performed today:
Vaccinations-Rabies, DHLPP, and Bordetella required for dogs and Rabies, FVRCP required for cats
Nail trim
Anal gland expression
Ear cleaning
Cold Laser Therapy for Extractions
None
Please list any additional procedures you would like performed that are not listed above.
Signature
Submit
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