Dentistry Consent Form

Owner's Name *

First Name Last Name

Pet's Name *

Email Address *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone number where you can be reached today *

Area Code Phone Number

Has anyone in your household experienced any COVID-like symptoms (fever, coughing, shortness of breath, etc.) in the last 2 weeks? *

Yes No

Has anyone in your household tested positive for COVID-19 in the last 2 weeks? *

Yes No

Has anyone in your household been exposed to anyone with a positive COVID-19 test result in the last 2 weeks? *

Yes No

If you answered "Yes" to any of the COVID-19 screening questions above, we will still see your pet, but we will take extra precautions. You are also welcome to have a friend bring your pet in for you and we will call you if we have any questions.

Would you like to update your pet's photo for their chart? If so, please click "Browse Files" and select their picture.

Browse Files

Would you like a text message or a phone call when your pet is ready to be picked up? *

Text message Phone call

Please list all medications/supplements your pet is on and the last time they were given. *NOTE: You can give all medications on the morning of surgery EXCEPT Enalapril, Tramadol, and any supplements. Medications can be given with a thin coating of peanut butter or cream cheese, or a piece of a pill pocket no bigger than a pinky nail. If your pet is diabetic, please feed a small meal the morning of surgery and HALF of their normal insulin dose.* *

Has your pet had any food since 10:00pm? *

Yes No

Does your pet have a history of seizures? *

Yes No

Does your pet have a history of adverse drug or vaccine reactions? *

Yes No

If yes, please describe the adverse drug and/or vaccine reactions.

Has your pet shown any signs of coughing or exercise intolerance? *

Yes No

Has your pet vomited or had diarrhea in the last 48 hours? *

Yes No

In the rare case of cardiac arrest (heart stopping), would you like us to attempt resuscitation, also known as CPR? (Please note that there will be an extra charge should we need to perform CPR on your pet.) *

Yes, please exhaust all efforts to try to resuscitate my pet. No, Please DO NOT RESUSCITATE.

This form is intended to promote a clearer understanding of the process involved in cleaning your pet's teeth. Please be aware of the following facts:

* A thorough evaluation of your pet's mouth, teeth, and gums cannot be accomplished without the aid of a general anesthetic. Therefore we may not be able to know in advance how many teeth may need to be extracted or how long the cleaning itself may take.

* Incidental findings, such as tumors, abscessed tooth roots, periodontal (gum) disease, cracked teeth, or Feline Odontoclastic Resorptive Lesions (a progressive, cavity-like disease in cats) are not uncommon.

* It is frequently necessary to change our treatment plan once the pet is anesthetized and a complete oral examination has been performed.

* Decisions about how to treat a particular problem are highly dependent on your dedication to follow up care, potential costs involved, aesthetics, and relative anesthetic risk.

* Certain specialized procedures (i.e. crowns and root canals) are not provided at our hospital, but are available through veterinarians that specialize in dentistry. These procedures are usually comparable, or more expensive than the same procedures in people. We can refer you to a veterinary dental specialist for follow up care, if you so desire.

* Certain disease processes are progressive and it is our intent to minimize pain. Therefore, we may elect to perform procedures that will avoid unnecessary pain in the future. (i.e. we may extract a tooth that is not yet loose, but has significant bone loss around it.)

* The removal of some teeth may result in unavoidable consequences, such as jaw fractures, or an inability of the pet to keep its tongue in the mouth.

In order to minimize the time that your pet spends under anesthesia, it is important that we know your desires before proceeding. This avoids delays involved with us trying to contact you to discuss your wishes; or worse yet…..us being unable to contact you at all at a crucial decision making point. In most cases, we make decisions based upon our values as if we were treating our own pets.

If you have any questions about the general anticipated degree of dental/oral work anticipated on your pet, please feel free to ask prior to your pet being admitted to the hospital for his/her procedure.

Please read CAREFULLY and check the appropriate box(es) below. I am aware that in the event that I check boxes 2 through 5, and I cannot be contacted, my pet may require an additional anesthetic procedure, at a significant additional cost, at a future date to pursue any additional problems: *

1) Please do any and all procedures you deem necessary to treat current problems, minimize any pain my pet might experience in the future from ongoing dental disease, or any other abnormalities discovered in the mouth and throat. I am aware that this may involve the extraction/removal of one or several teeth, oral surgery, obtaining skull radiographs (x-rays), taking biopsies, or other lab samples as indicated. 2) Please do any and all procedures you deem necessary, but do not exceed the high end of the estimate without contacting me. 3) Please do NOT, under any circumstances, proceed with anything more than routine cleaning and polishing without contacting me. 4) Please do NOT extract any "marginal" teeth, which might require extraction in the near future. I am aware that this will require significant follow up care to prevent rapid progression of disease and possibly increased pain until the next dental procedures are performed. 5) I would be interested in pursuing specialized care, even if this means leaving currently-diseased and potentially painful teeth in the mouth until I can make an appointment for my pet with a specialist.

Though complications are rare, there is inherent risk in surgery and general anesthesia. Companion Animal Clinic cannot be held responsible for any reactions your pet may have to these medications. By signing below you are giving consent to the staff and veterinarians of Companion Animal Clinic to anesthetize and perform the previously listed procedures (unless specifically declined) and acknowledge that you understand the special notes explained. By signing below you also agree to indemnify and hold the staff and veterinarians of Companion Animal Clinic free from and against any and all liability that may arise out of the performance of any of the procedures referred to above.

We will make every effort to reach you should questions or problems arise, however, by signing this form you authorize the doctor to treat your pet as deemed necessary should he/she be unable to contact you at the number(s) provided.

By signing below you certify that you are the owner or authorized agent for the above named animal and that you are responsible for him/her and have the authority to execute this consent.

By signing below you agree that you are responsible for payment in full of all above mentioned procedures and treatments at the time the patient is discharged.

If you miss or move this appointment without calling Companion Animal Clinic more than 24 hours in advance, your account will be charged a $35.00 no-show fee.

I have read and understand ALL of the above information.

Date *

Date

Signature *

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