Dental Consent Form

Dental Consent

Client

Client ID

Client

Name

First Name

Last Name

Address

City

State

Zip Code

Phone

Patient

Patient ID

Name

Species

Sex

Color

Markings

Birth Date

Weight (lb)

Authorization

I hereby authorize the use of such anesthetics as you deem advisable and performance of such surgical or therapeutic procedures as you determine to be indicated. I agree to indemnify and hold South County Animal Hospital harmless from and against any and all liability arising out of the performance of any of the procedures referred to above. Pre-Anesthetic blood work is required for all surgical procedures. Any patient that does not have current blood work (within 1 month) will have this service performed prior to any procedure requiring sedation and/or anesthesia. I hereby certify that I am the owner of the above-named animal or am responsible for it and have the authority to execute this consent. I hereby authorize the performance of the following procedure(s):

Although every effort is taken to appraise you of the work that needs to be performed for your animal prior to anesthesia, it is very challenging to know all that may be involved. Through the process of performing to complete dental prophylaxis and a thorough exam of your animal’s mouth, there may be additional problems encountered. We will always make a concerted effort to reach you at the number(s) you provided. However, in the event that we are unable to reach you, we will need to know what you prefer:

Dental Radiographs will be taken during the procedure. If abnormalities are noted in the radiographs that alter the intended procedure(s), we will attempt to contact you before proceeding. If we cannot reach you, we will proceed as authorized below.

Perform all procedures that are deemed necessary; this may include surgical extractions of the teeth, subgingival antibiotic therapy, mass removals, etc. I understand that there will be further costs associated with additional treatments.

Please only do what my pet presented for. Do not perform any additional procedures that I wasn’t aware of. I understand that this may mean that my pet has to undergo further anesthesia at a later date to complete the recommended procedure(s).

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Dental Consent Form

Client

Patient

Authorization

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