Pet's Name *

Breed *

Color *

Male or Female *

Male
Female

Spayed/Neutered? *

Yes
No

Species *

Canine
Feline

Age/Date of Birth *

Weight *

A dental exam can help us understand your pet’s oral health and aspects of your pet’s overall health. However, a thorough exam of your pet’s mouth, teeth, and gums cannot be accomplished without the use of anesthesia. In order to minimize the time that your pet is under anesthesia, it is important that we have clear instructions from you in advance with respect to how you would like us to treat any condition that we may discover during the dental exam.

I request that you:

Proceed with any procedure you deem necessary to treat any condition you identify during the dental exam, including any treatment to minimize any pain my pet may experience in the future from on-going dental disease.

Proceed with any procedure you deem necessary to treat any condition you identify during the dental exam, including any treatment to minimize any pain my pet may experience in the future from on-going dental disease.

Proceed with any procedure you deem necessary to treat any condition you identify during the dental exam, but do not exceed the below amount without contacting me first:

Proceed with any procedure you deem necessary to treat any condition you identify during the dental exam, but do not exceed the below amount without contacting me first:

Amount

Do not proceed with any procedure without contacting me first.

Do not proceed with any procedure without contacting me first.

I am the owner (or authorized agent of the owner) of the animal described above and have the authority to execute this consent. I understand that some risk always exists with anesthesia, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian and understand that it may be necessary to provide additional medical or surgical treatment to my pet in the event of unforeseen circumstances. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. Subject to my directions above, I hereby authorize the use of anesthetics and other medications, as well as any such additional treatment, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read and fully understand this consent. The fees associated with these services have been explained to me, and I agree to pay such fees in full at the time my pet is released from the hospital.

Cardiopulmonary Resuscitation *

Yes, if necessary, I do wish to have CPR performed.
No, thank you. If my pet passes away please do NOT resuscitate him/her

In the devastating event that your pet were to deteriorate and experience a cardiac arrest or respiratory arrest, no longer have a heartbeat or stop breathing our standard procedure would be to initiate Cardiopulmonary Resuscitation (CPR). Please note that costs of this can range from $300-$800+ depending on nature and duration of intervention. Under certain circumstances the veterinarian may recommend that resuscitation not be performed; as a pet owner you may prefer not to have resuscitation performed. In such cases you have the option to elect a Do Not Resuscitate (DNR) order.

Name *

First

Last

Best Contact Phone Number *

Alternative Phone Contact/Number

Email *

Date *

Signature *

Clear Signature

Schedule an Appointment

Dental Exam and Treatment

Consent Form

Schedule an Appointment

360-373-1465

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