Dental Consent Form Name* First Last Email* Phone*Secondary PhoneAlternate PhonePet Name* Pet Species*Select OneDogCatWould you like your pet microchipped during their procedure(s)?* Yes No Already Microchipped Would you like to your pet to go home with any dental care products?* Yes No Select which products you would like to take home:* Toothbrush Toothpaste Dental Chews The following are included in our STANDARD DENTAL CLEANING. Hospitalization. Pre-Anesthetic blood testing (CBC and Chemistry) and examination. Anesthesia (including pre-medications, induction agent, gas anesthesia, and monitoring). Intra-Oral dental radiographs. Ultrasonic enamel cleaning above and below the gum-line, rotary polish, and a pedicure. Post dental cleaning gingival laser therapy treatment. Fluid Therapy: IV Catheter or Subcutaneous. I have been shown a treatment plan for the procedure(s) listed above.* Yes No I would like to receive a treatment plan via* Phone Call Email I consent to have an area shaved for the IV catheter.* Initial hereDental Extractions or Extended Oral Surgery: I understand I may need to reschedule additional dentistry services at a later date if the veterinarian decides the procedure is not able to be performed in my pet's scheduled time and/or to avoid prolonged anesthesia time. Additional fees will apply.* Initial hereANTIBIOTICS AND/OR PAIN RELIEF MEDICATIONS: Will only be sent home if deemed necessary by the veterinarian and price varies. Is your pet currently on any medications?* Yes No Please list all medications** I understand that during the performance of the foregoing procedure(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or different procedure(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of veterinarian’s professional judgement. I also authorize the use of appropriate anesthetics and other medications and I understand the hospital support personnel will be employed as deemed necessary by the veterinarian. I have been advised as to the nature of the procedures or operations and the risks involved. I realize that results cannot be guaranteed. I understand that if my pet is kenneled overnight, there are no staff members present after hours. Signature* Reset signature Signature locked. Reset to sign again Δ
