Dental Consent Form

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Dental Consent Form

Please fill out this form as completely and accurately as possible.

Owner's Name(Required)

First Last

Email(Required)

Phone number(s) where I can be reached TODAY:(Required)

Cell Phone

Office Phone

Residence Phone

Pet’s Name(Required)

I understand that there are inherent risks and potential side effects in any dental/anesthetic procedure which may include but are not limited to the following:

What may at first appear as a routine cleaning, may actually become a treatment of oral infection or extraction.
It is not uncommon to see blood-tinged drinking water for 1 to 2 days following treatment.
When oral surgery is performed, hard foods, hard treats, chew toys, and oral play should be avoided for 2 weeks following the procedure while the delicate stitched gums are healing.
One or more infected or injured teeth may be detected during the procedure and additional x-rays, dental treatment and/or extractions will routinely be performed when indicated.
Periodontal treatment will not guarantee good oral health and patients with disease need constant management and repeat dental cleaning on a regular basis.
Drug reactions or allergies may occur.

I understand that there are inherent risks and potential side effects in any dental/anesthetic procedure which may include but are not limited to the the bullet list above.(Required)

I Understand

Procedure:

ANESTHESIA Pre-surgical blood tests and physical examination will enable us to assess and minimize the risk of anesthesia to your pet.
MONITORING We minimize anesthetic risk by monitoring heart rate and rhythm, respiration rate, oxygenation, and depth of anesthesia during the procedure.
CATHETERIZATION For sterility, hair will be shaved over a vein on the leg so that an intravenous catheter can be placed to provide us with an easy route to administer medications and fluids during the procedure.
CLEANING An ultrasonic scaler is used to remove calculus from the teeth. The teeth are then polished, and a fluoride foam is applied.
PAIN MANAGEMENT We will proactively manage pain by administering appropriate pain medications. As with any drug, side effects may be associated with the administration.

Authorization for Hospital Use

I authorize anesthesia and dentistry/oral surgery for my pet. I understand that there are rare complications associated with any anesthetic or surgical procedure. I understand that an estimate of fees has been given but the final cost will depend on the length of the procedure which varies from patient to patient. The more extensive extraction procedures can take several hours to finish. I understand additional treatment may incur increased expense.(Required)

I Agree

If during the procedure any unforeseen dental procedures become necessary in the veterinarian’s professional judgment: (please select one of the following)(Required)

I prefer that you proceed with additional procedures including the extraction of teeth.

I prefer to be called before any additional procedures, other than emergencies, are performed. If I cannot be reached by phone, I authorize you to proceed with the procedure or extraction.

If I cannot be reached by phone, I do not authorize any unforeseen dental procedures such as extractions.

I have read and understand the “CONSENT FOR DENTAL TREATMENT”(Required)

Signature

Date(Required)

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Dental Consent Form

Dental Consent Form

Procedure:

Authorization for Hospital Use

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