Dental Consent Form Dental Consent Form Dental Consent Form Name * Name First First Last Last Pet's Name * Phone * Email * When was the last time your pet ate? * Please list any medications that your pet is taking Medication Dosage/Frequency When last dose was given plus1 Add another medication minus1 Remove a medication Has your pet ever had an adverse reaction to any medication? * Yes No If yes, please describe ** Please Read Carefully and Sign ** Your pet is here today for anesthesia and a surgical procedure. Rest assured that advances in anesthesia and surgery have made routine procedures relatively safe with a low rate of complications. Nevertheless, occasional problems can arise due to pre-existing conditions not evident during routine pre-anesthetic examinations. Please be aware that dental procedures are performed throughout the day. The order is determined at the veterinarian’s discretion after all patients have been admitted. You will be called when your pet’s procedure has been completed. Discharge times may be as late as 5pm-7pm. OFTEN ISSUES WITH THE TEETH MAY NOT BE NOTICED ON ROUTINE EXAMINATIONS BUT ARE DETECTED ONCE THE PET IS ANESTHETIZED. TO EXTRACT THESE TEETH, WE NEED THE OWNER’S CONSENT. I UNDERSTAND SOMEONE AUTHORIZED TO MAKE MEDICAL/FINANCIAL DECISIONS MUST BE AVAILABLE TO SPEAK WITH THE DOCTOR AT ALL TIMES DURING THE DAY OF THE PROCEDURE. If I need to be contacted, I can be reached at the following phone numbers, we will text you when the procedure starts. Phone Phone Teeth Extraction * If I am unable to be reached by phone, I give permission to extract any teeth necessary. If I am unable to be reached by phone, I do not give permission to extract any teeth. I am fully aware my pet will be woken up from anesthesia within 15 minutes of phone call and I will need to book a separate procedure at another time. Your pet can be micro-chipped while he/she is here today. If you are interested in a microchip, please speak to a technician. * Yes, I would like my pet microchipped today. No, I decline this service today To ensure the safety of all animals in our care, please be aware that if your pet is not fully vaccinated and contracts an illness while staying with us, we cannot be held responsible for any resulting medical cost. * I understand I, the undersigned, have read and fully understand the above information and procedures. If fleas are present upon examination, we will apply a flea elimination product to your pet and the charge will be added to your invoice. Please understand that this is necessary to safeguard our hospital. Signature * signature keyboard Clear Date * Email * Submit If you are human, leave this field blank.
