Dental Consent Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet’s before your visit.

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Dental Consent Form

If you have any questions, please feel free to email us at contact@hartanimalclinic.com.

This form may be printed off as a pdf and brought in at our appointment or filled out in the space below and automatically sent to our clinic.

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Name *

First

Last

Email *

Pet's Name *

Number I can be reached the day of the procedure *

A dental exam can help us understand your pet’s oral health and aspects of your pet’s overall health. However, a thorough exam of your pet’s mouth, teeth and gums cannot be accomplished without the use of anesthesia. In order to minimize the time that your pet is under anesthesia, it is important that we have clear instructions from you in advance with respect to how you would like us to treat any condition that we may discover during the dental exam.

Please Choose One *

Proceed with any procedure you deem necessary to treat any condition you identify during the dental exam, including any treatment to minimize any pain my pet may experience in the future from on-going dental disease.
Proceed with any procedure you deem necessary to treat any condition you identify during the dental exam, but do not exceed my written estimate without contacting me first.
Do not proceed with any procedure without contacting me first.
Other

Our greatest concern is the wellbeing of your pet. We will perform a physical examination before administering anesthesia. However, disorders of the liver, kidneys, or blood, are not detected unless blood testing is done. Abnormalities of any of these may increase anesthetic risk. Also establishing baseline levels for your pet is important as they age. For these reasons we highly recommend pre-anesthetic blood screens.

I accept
I decline

I am the owner (or authorized agent of the owner) of the animal described above, and have the authority to execute this consent. I understand that some risk always exists with anesthesia, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian and understand that it may be necessary to provide additional medical or surgical treatment to my pet in the event of unforeseen circumstances. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. Subject to my directions above, I hereby authorize the use of anesthetics and other medications, as well as any such additional treatment, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read, and fully understand, this consent. *

I have read and understand

The fees associated with these services have been explained to me, and I agree to pay such fees in full at the time my pet is released from the hospital. *

I have read and agree

Signature *

Clear Signature

Today's Date *

Name

Dental Consent Form

Dental Consent Form

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