Dentistry Consent Form printable pdf download

Date ______________________

DENTISTRY CONSENT FORM

Owner’s Name _______________________________________ Pet’s Name__________________________________

Phone numbers (1st) ___________________________ (2nd) ____________________________

Email (optional) _________________________________________________________________________________

Unless otherwise specified by a doctor, please call between 1-3 p.m. to check on your pet and his/her pickup time. We may want to

schedule a brief appointment at pick up to discuss your pet’s dentistry.

Does your pet have a microchip? ……………………………………………………………………. YES

Has your pet eaten this morning? ……………………………………………………………………. YES

After your pet’s procedure, we would like to offer your pet a small meal. What can we feed your pet?

__________________________________________________________________________________________

Has your pet had morning medications (if any) ……………………………………………………… YES

Does your pet need a prescription refill today?.… Yes

Please specify ____________________________

Have you received an estimate for services? ……………………….……………………………… YES

If not, a staff member must be able to reach you with an estimated cost prior to treatment.

Our goal is to preserve all teeth and extract only those that are hopelessly diseased. During the oral examination and

cleaning we may discover additional problems. Please refer to the questions below. In the event we are unable to

contact you, we will perform only those procedures you have marked below.

Permission is granted to:

1. Give anesthesia to perform dental exam, dental x-rays and cleaning………………..…………. YES

2. Extract any diseased teeth………………………………………………………………………. YES

3. _________ I authorize additional procedures the doctor feels is necessary and will pay the additional charges.

_________ I authorize necessary procedures / expenses ($250 minimum) up to $ _____________________

4. If medication is sent home, which of the following would you prefer administering?

Liquid

Pills

5. What type of dental care are you willing and/or able to perform at home?

Dental Diet

Daily Teeth Brushing

Chewing Products

Weekly Application of Oravet

Additional Procedure being done today: _________________________________________________________

Our greatest concern is the well being of your pet. Prior to anesthesia, we will perform a pre-surgical evaluation.

However, many conditions, including disorders of the liver, kidneys, or electrolyte function, are not detected unless

blood testing is performed. Our laboratory will perform these tests and we will evaluate the results prior to anesthesia

and/or surgery.

In the event of an emergency, it is expressly understood that the hospital and authorized personnel shall have authority

and permission to prescribe for, treat and/or perform surgery upon the described animal. Should your pet require care

from a Veterinary Specialist or Emergency Hospital, we will provide them with your current address and phone number.

To prevent the spread of infectious diseases and parasites, hospitalized animals must be current on all vaccines and be

free of external and internal parasites. I hereby authorize Best Friends Animal Hospital to provide the vaccines and

parasite control when needed.

SIGNATURE ____________________________________________ DATE:__________________________

Dentistry Consent Form