Clone of Botetourt Veterinary Hospital Dentistry Consent Form

Client Name

Patient Name

Address

Telephone:

This is a number that we can reach you today while your pet is in the clinic with us.

Email

example@example.com

Procedures

What is your understanding of the procedure your pet is receiving while in our care?

Date

Has your pet had any food since midnight last night?

Has your pet been coughing, wheezing, or breathing hard?

Has your pet been vomiting or having diarrhea?

Does your pet have any allergies OR Has your pet ever had an adverse reaction to a medication?

Additional Recommended Services: Please check if you authorize services to be preformed while your pet is with us today.

I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize the above procedure to be performed by Botetourt Veterinary Hospital. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian.

I have been advised as to the nature of this procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. Procedure risks include serious bodily injury (including, but not limited to: eye injuries, broken teeth, broken jaw) or death. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian's professional judgment. I accept responsiblity for any result in additional charges.

We may identify additional problems during the dental procedure that could not be identified beforehand, such as broken or abcessed teeth, bone loss, deep pocketing, etc. These problems are best dealt with while your pet is under anesthesia.

I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital).

In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risk will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference:

I have read and understand the information printed above.