Dentistry Consent Form To Print
Pet's name: ____________________________________
Owner's Name: __________________________________.
I, the undersigned owner or owner's agent of the pet named {NAME}, have been informed that my pet is in need of preventive or therapeutic dental care and consent to the appropriate procedures described to me by staff veterinarians at Mountain View Veterinary Hospital. These procedures include but are not limited to the following: 1) dental prophylaxes (routine teeth cleaning and polishing), 2) extractions, 3) gingival flap surgery to close gaps left by extractions, 4) root planings, 5) additional dental radiographs, and/or 6) antibiotic gel implants.
Should any dental procedures be necessary and desirable in the veterinarian's professional judgment:
I prefer that you proceed with all necessary dental procedures
I prefer to be called before any additional procedures, other than emergencies. If I cannot be reached, I authorize you to proceed with all necessary dental procedures not to exceed the amount of $500 or $__________ . I am aware that if the necessary procedure costs exceed this amount then the procedures will not be done. A second dental procedure will need to be scheduled at a later date to finish needed procedures.
If I cannot be reached by phone, I do not authorize any unforeseen dental procedures. I am aware that this means infected teeth will be left untreated.
I am aware that dental procedures for animals require the use of anesthesia to: (1) maximize visualization of the gums, teeth, and oral cavity, (2) minimize movement and discomfort, and (3) provide for the safety of the pet, doctors, and hospital staff. I understand that some risks always exist with anesthesia and dental procedures, and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before these procedures are initiated. Should some unexpected life-saving emergency care be required and the attending veterinarian be unable to reach me, the staff has my permission to provide such treatment, and I agree to pay for such care.
I have been informed that examinations under anesthesia often reveal abnormally loose teeth that fall out or should be extracted to prevent oral discomfort and ongoing infection of surrounding bone. I also have been informed that the loss or removal of one or more unhealthy canine teeth occasionally allows for an awkward protrusion of the tongue to one side or the other. Nevertheless, all questions and concerns I have about the recommended dental procedures have been answered to my satisfaction.
I understand that an estimate of the fees for the above dental care will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered. I agree to assume financial responsibility for the remaining fees, and provide payment via cash or credit card at the time my pet is discharged.
I agree to indemnify and hold Mountain View Veterinary Hospital harmless from and against any and all liability arising out of the performance of any of the procedures referred to above.
What phone number(s) can you be reached at today: ________________________________
Date: _________________________
Signature of Owner or Agent: __________________________________
Owner's Name: __________________________________.
I, the undersigned owner or owner's agent of the pet named {NAME}, have been informed that my pet is in need of preventive or therapeutic dental care and consent to the appropriate procedures described to me by staff veterinarians at Mountain View Veterinary Hospital. These procedures include but are not limited to the following: 1) dental prophylaxes (routine teeth cleaning and polishing), 2) extractions, 3) gingival flap surgery to close gaps left by extractions, 4) root planings, 5) additional dental radiographs, and/or 6) antibiotic gel implants.
Should any dental procedures be necessary and desirable in the veterinarian's professional judgment:
I prefer that you proceed with all necessary dental procedures
I prefer to be called before any additional procedures, other than emergencies. If I cannot be reached, I authorize you to proceed with all necessary dental procedures not to exceed the amount of $500 or $__________ . I am aware that if the necessary procedure costs exceed this amount then the procedures will not be done. A second dental procedure will need to be scheduled at a later date to finish needed procedures.
If I cannot be reached by phone, I do not authorize any unforeseen dental procedures. I am aware that this means infected teeth will be left untreated.
I am aware that dental procedures for animals require the use of anesthesia to: (1) maximize visualization of the gums, teeth, and oral cavity, (2) minimize movement and discomfort, and (3) provide for the safety of the pet, doctors, and hospital staff. I understand that some risks always exist with anesthesia and dental procedures, and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before these procedures are initiated. Should some unexpected life-saving emergency care be required and the attending veterinarian be unable to reach me, the staff has my permission to provide such treatment, and I agree to pay for such care.
I have been informed that examinations under anesthesia often reveal abnormally loose teeth that fall out or should be extracted to prevent oral discomfort and ongoing infection of surrounding bone. I also have been informed that the loss or removal of one or more unhealthy canine teeth occasionally allows for an awkward protrusion of the tongue to one side or the other. Nevertheless, all questions and concerns I have about the recommended dental procedures have been answered to my satisfaction.
I understand that an estimate of the fees for the above dental care will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered. I agree to assume financial responsibility for the remaining fees, and provide payment via cash or credit card at the time my pet is discharged.
I agree to indemnify and hold Mountain View Veterinary Hospital harmless from and against any and all liability arising out of the performance of any of the procedures referred to above.
What phone number(s) can you be reached at today: ________________________________
Date: _________________________
Signature of Owner or Agent: __________________________________