Happy Female Veterinarian Holding Yorkshire Terrier
Little Green Leaves Two Tone

Dental Procedure Consent Form

Please fill out and submit this form 24 hours prior to your appointment.

Please withhold food and water 12 hours before your pet's admission appointment.

Dental Procedure Consent Form
Name
Name
First Name
Last Name
Address
Address
City
State/Province
Zip/Postal
I, the undersigned owner, or owner's authorized agent of the above pet certify that
Is your pet on medication?
I have been informed that my pet is in need of preventive or therapeutic dental care and hereby consent to the appropriate procedures described to me by the veterinarian and her staff at this facility. These procedures include but are not limited to the following: 1) dental prophylaxis (routine teeth cleaning and polishing), 2) extractions, 3) oral surgery to close gaps left by extractions, 4) root planings, 5) dental x-rays, and 6) antibiotic gel implants.
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, doctor, 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 veterinarian before these procedures are initiated.