Dental Consent Form

Your pet’s dental care is easy with our streamlined consent form—a hassle-free solution for pets and their caring owners.

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Dental Consent Form

Prior to your pet’s dental procedure, please fill out the form below. To ensure your pet gets the best care we can offer, please fill out the form completely. Please Note: All * fields are required.

Owner Name *

First

Last

Email *

Phone *

Pet's Name *

Animal’s Possessions

Procedure *

Procedure Date *

Procedure Authorization

I hereby authorize the performance of the dental procedure listed above, including the placement of an IV catheter and pre-anesthetic bloodwork. I understand this procedure requires to be placed under anesthesia and that all procedures involving general anesthesia carry a very small risk of complications, including death. If becomes stressed during the blood draw or catheter placement, I authorize the Doctors to administer sedation to allow catheter placement and a blood draw prior to the procedure.

If any additional procedures are needed, the veterinarian will attempt to contact you at the number you provide below. If I cannot be reached at the number provided, I authorize the veterinarians to perform additional procedures they deem medically necessary for ’s well-being. I understand that added procedures will be an additional expense. I assume financial responsibility for all services rendered and agree that payment is due on the date of the procedure.

Microchip

Every two seconds, a family pet is lost. Many are never reunited with their families because they cannot be identified. Because of these statistics, we suggest microchips whenever a pet is sedated. HomeAgain chips are known nationwide and have a 24-hour hotline to match chip numbers with the owner’s contact information.

Our records indicate your animal ’s microchip number is:

No microchip?

My animal does not have a microchip, please implant one during their procedure. I understand  that the cost of the microchip is $68.00 in addition to the cost of procedure.
I hereby decline the implanting of a microchip.

Section II: Parasite Control

For the protection of all our patients, any pet left for treatment will be inspected for external parasites (fleas, ticks, etc.). If parasites are found, we will apply the appropriate topical treatment at the single dose price. Please list any flea, tick or ear mite medication recently applied

CPR/DNR statement

All patients being treated are required to have an advanced directive in the form of a CPR (Cardiopulmonary Resuscitation) or DNR (Do Not Resuscitate) code. Please select ONE option below. *

I request CPR on my pet if my pet suffers from a cardiac or respiratory arrest. I understand that CPR does not guarantee that my pet will have a favorable outcome. Further, I understand that there are fees associated with CPR that would increase the cost of my pet’s care while the hospital is making every effort to contact me.
I DO NOT want CPR performed on my pet. I have elected to have a DNR order placed on my pet’s record. I understand that my pet will pass away in the event of cardiac and/or respiratory arrest.

I am the owner or responsible agent for the patient, and I have the authority to provide this advanced directive. I am over the 18 years of age. *

I have read and agree

Owner/Owner’s Agent Name *

First

Last

Signature *

Clear Signature

Today's Date *

Website

Dental Consent Form