Dental Consent Form

Thank you for taking the time to pre submit the Dental Consent Form before your pets dental appointment.

Section 1: Owners information

Owner / Agent For Owner (required)

Your Email (required)

Section 2: Patient information

Pets Name:

Weight (in pounds):

Date:

Section 3: Emergency contact info - PLEASE READ:

Your pet has been scheduled for a Dental Prophylaxis (teeth cleaning) for today. The need for extractions is always a possibility since we are unable to probe the mouth/teeth for problem areas while your pet is awake. Dental extractions, minor surgery, of dental x-rays may be warranted after a through exam of the mouth/teeth once your pet is anesthetized. Therefore it is imperative that we are able to contact you, if we need to, while your pet is anesthetized.

Please select ONE of the following:

I authorize the attending veterinarian to perform any extractions, x-rays, or procedure deemed necessary while my pet is anesthetized.

Please attempt to contact me prior to any additional procedures are performed on my pet. If you are unable to contact me, I authorize any additional treatment deemed necessary.

Please contact me regarding any additional procedures. If I am not available, DO NOT PROCEED. I understand this will require my pet to undergo anesthesia at a different time and at an additional cost.

Home Phone:

Work Phone:

Cell Phone:

Section 4: Consent to Perform Dentistry:

I am the owner or agent of the animal listed above. I have the authority to
execute this consent and I am over the age of 18 years. I hereby authorize and direct the veterinarians of Abby Pet Hospital to perform the above described procedure(s). The nature and purpose of the procedure(s) has been explained to me and I understand that no guarantee exists as to the result of diagnoses and treatment of the said animal. I have had the fees outlined to me and agree to pay in full for all services rendered, including those deemed necessary for medical or surgical complications or for any unforeseen circumstances. I agree to pay in full for all services rendered at the time of discharge. If unforeseen conditions arise, I authorize the attending veterinarian to do what is in the best interest of my pet's health.

I agree that I have read and understand this consent form

Owner/Agent Signature:

Date:

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