Dental Consent Form - Clovercroft Veterinary Hospital
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1Clovercroft Veterinary Hospital
DENTAL CONSENT FORM
Pet’s Name: ________________________________________________________________
Client/Authorizing Agent Name: __________________________________________________________________________
Phone Number at which I can be reached immediately and at all times today: ___________________________________
Name of Procedure(s): ___________________________________________________________________________________
____________________________________________________________________________________________
During this Procedure:
________I give permission to do what is medically necessary, including removal of diseased
tooth/teeth. I am placing no restrictions on the medical team regarding removal of teeth and
give permission for the doctor to remove any/all necessary.
________I do NOT give permission to do what is medically necessary regarding removal of teeth at this
time. If the doctor performing the dental procedure feels it is necessary to remove any
tooth/teeth, it is my wish that the doctor call me to discuss extractions prior to removing any
teeth. Please realize that the doctor cannot make the decision as to whether any teeth need to
be removed until your pet is anesthetized and the dental cleaning is in progress. If you elect
to have the doctor call you prior to extracting any tooth/teeth it is essential that you answer
our call immediately. Failure to answer our call may mean that the dental procedure
is completed prior to speaking with you and no extractions are performed.
I UNDERSTAND THAT MY PET MAY HAVE TO UNDERGO ANOTHER ANESTHETIC PROCEDURE TO
ADDRESS DENTAL PROBLEMS IF CONTACT WAS NOT POSSIBLE. I ACCEPT ALL RISKS AND FEES
ASSOCIATED WITH ANOTHER PROCEDURE SHOULD SUCH AN EVENT OCCUR.
Estimated Cost/Fees for Routine Dental Cleaning & Prophylaxis Procedure
$201.29
Estimated Cost/Fees for tooth removal (extraction) vary with type of tooth
$25-100
removed, difficulty of extraction(s), and number of extractions
Other Recommendations and Fees frequently associated with Dental Work
I would like my pet to have full blood screen (complete blood counts, full chemistry panel)
Recommended for pets 7 years and older or pets with chronic medical conditions
such as diabetes, kidney disease, thyroid, etc. In some situations, these tests
may be required before anesthesia and dental procedure.
_____ I give permission
______ I do NOT give permission
$134.70
Instead of full blood screen, I would like my pet to have mini pre-anesthetic blood work
(screening tests for anemia, kidney disease, liver disease and dehydration)
$53.35
_____ I give permission
______ I do NOT give permission
Pain Medication(s):
(fees vary by weight and species of pet)
$25-$50
_____ I give permission
______ I do NOT give permission
It is possible that other fees might be incurred today including antibiotics, other medication(s) as well as
fees for other procedures performed, at the request of the client, during the anesthetic procedure.
I understand that the procedures agreed to above will be performed under general anesthesia for my pet today. I am
aware of and accept all risks associated with these procedures and I agree to hold harmless the medical team should
unanticipated liability arise out of the performance of the procedures above. I agree to pay all charges for today’s
procedures when my pet is released from the hospital.
Signature of Pet Owner/Authorized Agent:______________________________________________ Date ________________
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