Consent For Dental Prophylaxis Form

Client

Pet Name

Date

Your pet is being admitted for professional Dental Care, which is very a important preventative health care procedure. It is necessary to anesthetize your pet to do a thorough job. Anesthesia involves some inherent risk, but we will monitor your pet closely to insure his or her safety and well-being. Our staff is well trained, we use state-of-the-art monitoring equipment, and a doctor will be present for the entire procedure. If a problem arises, we will institute whatever measures are needed to stabilize your pet. Your consent to this procedure is also an agreement to pay for all care your pet requires today.

Pre-Anesthetic Blood Work is the for the safety and wellbeing of your pet. Bloodwork will not be required if your pet has had bloodwork (CBC/Chem10 or greater) performed within the last 90 days and has assessed as being NORMAL. A credit of $67 will be applied

Date last bloodwork performed

Staff Initial

After the teeth are cleaned, the doctor will examine the mouth to assess the health of the tissues. It is important that we have a phone number where you can be reached if consultation is necessary while your pet is under anesthesia. In many instances of serious damage to a tooth or a serious loss of gum tissue and supporting bone, tooth extraction is the best treatment. If there is such a problem the doctor will call you. It is important to give us a phone number where you can be reached at any time today, since the Doctor may need to consult with you while your pet is under anesthesia. Tooth extraction is not included in base pricing and varies.

I can be reached at

Today

If you cannot be reached, do you consent to tooth extraction if needed? (Additional fees apply)

Owner Signature

Staff Initials

Date