Dental Procedure Consent Form

Client Name*

First NameLast Name

Main Contact Number*

Please enter a valid phone number.

Secondary Phone Number

Please enter a valid phone number.

Pet Name*

I am the owner or agent for the owner of the above-described animal and have the authority to execute this consent. I have had an opportunity to ask any questions to the technician or doctor prior to signing this consent form.

Initials if OK Pre-anesthetic Exam (prior to anesthesia unless exam performed within past 6 months). **Recommended to check heart and lungs prior to anesthesia.
Initials if OK Pre-anesthetic blood testing (prior to anesthesia) *Add $71.00. **Recommended to catch any illnesses or organ disease that may prevent us from undergoing procedure OR change anesthetic protocol.
Initials if OK IV Catheter placement (prior to anesthesia) *Add $38.00. **Recommended to run IV fluids during procedure to keep blood pressure normal and provide immediate access to veins in case of emergency.
Initials if OK Basic dental procedures include oral exam, dental scaling, and polishing under anesthesia.
Initials if OK Appropriate pain medication will be given as needed for extractions, this is NOT optional. This will add up to $35.00 depending on weight. If needed, please ask for an estimate.
Initials if OK Dental radiography. This is recommended for ALL dental procedures in order to assess the roots of each tooth and decide if intervention is necessary. Despite looking healthy on the outside, tooth roots can often have disease that left untreated may result in abscesses pain, or bone loss. This will add an additional $100 to the bill.

Additional procedures can be performed while my pet is under anesthesia such as x-rays, wart removals, easy mass removals, fine needle aspiration, etc. I would like to add on the following: list procedure(s). .

I understand this will add cost to my total bill and may not be on the estimate.
Initials of authorized person Please type your initials to acknowledge this statement.

ACKNOWLEDGEMENTS

Initials of authorized person Decline Dental x-rays: I understand I have declined dental radiographs. This does not impact basic dental procedures as listed above, however, does limit full interpretation of teeth roots. Without dental x-rays, diseased teeth under the surface that are not loose could be missed on oral exam.

Oral Surgery / Extractions: Damaged teeth can result in pain and infection including sites near or distant to them. Teeth will be recommended for extraction based on several reasons upon dental exam. This could include, but is not limited to, exposed tooth roots, discolored tooth, broken tooth, extreme gingival recession, loose teeth, and tooth root abscesses. Also, teeth that looked okay on initial inspection may be revealed to be diseased after removing a hard cement-like plaque called calculus and will need to be extracted.
Initials of authorized person Please type your initials to acknowledge this statement.

I understand loose teeth can fall out without an extraction when calculus is removed during routine cleaning or from simple friction while cleaning. This CANNOT be prevented, and is NOT considered an extraction.
Initials of authorized person Please type your initials to acknowledge this statement.

Initials I consent to extract any teeth as recommended by the Doctor.

Initials I DO NOT consent to extract any teeth as recommended by the Doctor. I understand by choosing this option, I am waking my dog from anesthesia against medical advice without recommended extractions and will be leaving disease teeth that could create issues in the future such as infection or pain. Initials if understood

Initials to select and agree Please call me prior to any extractions.

If I cannot be reached: (please initial one option below)
Initials proceed with extractions
Initials do not proceed with extractions

Cost limits: Because anesthesia is necessary to evaluate your pet's oral health, a full treatment plan and cost estimate cannot be exactly determined prior to the start of the procedure.
I understand any treatment plan or estimate given prior to procedure is not always what the procedure will cost when completed. I understand procedures of significant cost may be necessary to treat severe periodontal disease and if cost reaches over
$ enter maximum dollar amount, I want to be contacted.

If I cannot be contacted please: (please initial one option below)
Proceed Initial
Do not proceed Initial

I understand the staff at South Rhea Animal Hospital will do everything possible to ensure the safety of anesthesia, but unforeseen complications, while rare, can occur.

In the event of an adverse event such as respiratory or cardiac failure,
Initial if you agree I consent to all measures of resuscitation within reason for doctor and staff to perform until I can be contacted or,
Initial if you disagree I do NOT consent to resuscitation.

I have been advised as to the nature of the procedures and the risks involved. I realize that no guarantees can be ethically or professionally made in regards to results or cure.
I hereby consent to and authorize the procedure as indicated above.
I authorize the use of appropriate anesthesia and pain relief medication as needed before, during, and after the procedure as the doctor sees fit.
Authorization for further procedures may be provided by telephone in consultation with the doctor(s) or staff.
I assume full responsibility for all treatment expenses incurred, and payment is due in full at time of discharge unless other arrangements have been consented to by Doctor(s).

Signature of Authorized*

Date*

Date

Dental Procedure Consent Form

Procedures