Dental Consent Form
Surgical Procedure
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Procedure Date
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Month
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Day
Year
Date
Patient Name
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Patient Age
Patient Sex
Patient Breed
Client Name
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What has your pet had to eat and drink today?
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When was the last time they had something to eat or drink?
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Is your pet on any medications or supplements? Please provide a complete list.
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Additional Treatment
These procedures, the medical necessity and costs have been explained to me to my satisfaction. I understand that I may call for updates on my pet as I deem appropriate. I understand that no guarantee has been made to me regarding the outcome of my pet’s treatment or procedure. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is initiated. Should some unexpected life-saving emergency care be required and the attending veterinarian is unable to reach me, I:
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CONSENT to additional life-saving treatment at the discretion of the attending doctor and agree to pay for all related fees. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made.
DO NOT CONSENT to additional life-saving treatment at the discretion of the attending doctor and agree to pay for all related fees. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made.
Dental Extractions
Extractions are done at our doctor's discretion based on their medical expertise. We do not call before we extract. Teeth that need to be extracted cannot always be fully identified until the pet is under anesthesia, so the provided estimate may not include all the necessary extractions. The doctor will only extract teeth if they have any of the following issues: severe dental disease, cavities with exposed root/pulp, severe cracks or fractures, dead teeth or teeth with advance mobility.
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I CONFIRM that I understand the extraction policy and that it may change the cost on the provided estimate
Pre-Anesthetic Blood Testing
Our greatest concern is the well-being of your pet. We will monitor your pet’s heart rate, respiratory rate, pulse oximetry, temperature, and blood pressure throughout surgery to ensure their safety. This technology, combined with pre-anesthetic blood screening, helps us minimize the risks associated with anesthesia. To further protect your pet, we will perform a Complete Blood Count (CBC) and a Chemistry 10 (Chem 10) panel on all pets undergoing anesthesia. This allows us to check vital organ function, detect underlying health conditions, and ensure your pet is stable for the procedure. If you would like a more comprehensive health screening, we also offer expanded chemistry panels that provide a broader look at your pet’s organ function. These panels are especially valuable for establishing a baseline of your pet’s internal health, which can be useful for tracking changes over time as your pet ages. This information can help us detect health concerns early and provide better long-term care for your pet. Please let us know if you are interested in this additional testing option.
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I want a CBC and full chemistry (SDMA/T4 and Chem 17) ($175-$243)
I'm satisfied with the baseline bloodwork.
Microchip
If your pet does not already have a microchip for identification, would you like us to implant one while they are under anesthesia? These microchips are added to our software and to a national registry so your pet can be identified if they get lost.
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Yes, please implant a microchip in my pet. ($51.99)
No, thank you.
Post Operative Laser Therapy
We recommend photobiomodulation (laser therapy) to help alleviate inflammation and speed healing. This is typically used for arthritis or other types of chronic inflammation, but we also use it on the gums after dental scaling or extractions. Please select from the options below:
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Yes, please use the therapy laser on my pet's gums. ($18)
No, thank you.
Elizabethan Collar
An elizabethan collar will be sent home with your pet in the case of extractions. If you do not want an elizabethan collar, you must decline it below:
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Yes, I will take an elizabethan collar home today. ($10)
No, I decline an e-collar. Do not send one home with my pet.
Picture Message/Text
If time permits, would you like a picture message of your pet sent to your cell phone after the surgical procedure? (Your carrier charges may apply)
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Yes
No
Can we use photos of your pet on our social media pages?
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Yes
No
Financial Responsibility
I understand that an estimate of the costs for veterinary services will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered and during this pet’s ongoing medical treatment. If my pet is hospitalized, I agree to pay a deposit of 60% of the estimated fees on the provided estimate at the time of hospitalization and assume financial responsibility for the balance of all services rendered, due in full on a cash, credit card, CareCredit, ScratchPay or check basis at the time your pet is discharged. If my pet is hospitalized beyond the first day at this facility, I understand that veterinary care during nighttime hours and/or weekends is provided at the discretion of the attending veterinarian. Continuous presence of personnel is not provided during these hours. If I desire that my pet have supervision when this facility is closed, I may elect to transfer to a local emergency clinic, at my expense, where overnight veterinary supervision is available. PLEASE NOTE: Our hospital policy is to keep all surgery patients overnight unless you are informed otherwise by a Doctor or other member of our team.
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Yes
No
Surgical Consent
I, being responsible for my pet, having the authority to do so, grant my consent to receive treatment, prescribe for and/or operate upon my pet as noted above. I also agree that after consultation with me, the hospital’s doctors may prescribe medication for, treat, hospitalize, sedate, anesthetize and/or perform surgery on the animal. Lone Tree Animal Care Center is to use all reasonable precautions against injury, escape or death of my pet, but is not held liable or responsible in any matter, as I thoroughly understand I assume all risks. I, the undersigned owner, authorized agent of the owner or Good Samaritan responsible for seeking veterinary care for my pet certify that:
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I AM over eighteen years of age
I AM NOT over eighteen years of age
Signature of Owner or Authorized Agent
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Signature Date
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Month
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Day
Year
Date
Other individuals authorized to make decisions about my pet:
Phone numbers where I can be reached:
Submit
Should be Empty: