Pet's Name *

Client's Name *

First

Last

Email *

Phone *

I am the owner or agent for the owner of the above-described animal and have the authority to execute this consent. I have had an opportunity to discuss the procedure with the doctor. My questions have been answered to my satisfaction. *

I have read, understand, and agree.

BASIC DENTAL PROCEDURES: Oral exam, dental scaling and polishing under anesthesia. *

I have read and understand.

DENTAL RADIOGRAPHS: X-rays are vital in the evaluation of your pet’s dental health to allow detection of problems that cannot be seen during an oral exam, as well as an aid in making treatment strategies and to evaluate treatment outcomes. We perform full oral radiographs on all cases (Dental extractions cannot be done without x-rays). *

I have read and understand.

ORAL SURGERY & EXTRACTIONS: Damaged teeth often cause pain and disease in the mouth and at sites distant to it. Damaged teeth usually require surgical extraction to promote good oral health. Often, in pets with significant periodontal disease, numerous teeth must be extracted. As in other types of surgery, oral surgery techniques are designed to facilitate healing and minimize pain. Costs vary from $215.00 for a simple extraction to $360.00 for a complicated extraction (includes local anesthetic and extraction). *

Please extract any teeth as recommended by Dr.
Do NOT extract any teeth.
Please call prior to any extractions.

If I cannot be reached: *

Please DO proceed with extractions.
Please do NOT proceed with extractions.

COST LIMITS: Because anesthesia is necessary to evaluate your pet’s oral health, a full treatment plan and cost estimate cannot be determined prior to the start of the procedure. Procedures of significant cost may be necessary to treat the periodontal disease present. To guide us in these situations, indicate below if you would like to be contacted in the event higher costs procedures are anticipated. *

Contact me prior to performing procedures resulting in charges exceeding the given estimate
Proceed with any indicated procedures even if charges may exceed the given estimate. You do not need to contact me first.

If I cannot be reached: *

Please DO continue with the procedure
Please do NOT continue with the procedure

ORAVET DENTAL SEALANT: Oravet is a dental sealant product recommended by the Veterinary Oral Health Council (www.VOHC.org). Oravet binds electrostatically to tooth enamel, creating an invisible barrier that helps prevent plaque-forming bacteria from attaching. It has been proven to significantly reduce the formation of plaque and calculus. Total cost today is $63.88 with the kit. ($28.11 application and $35.77 for the home kit, if your pet is over 40 pounds, the application charge is $36.83). Oravet is applied once a week, the home kit should last about 8 to 16 weeks depending on the size of your pet’s mouth. Dogs will be sent home with a sample treat to try out before purchasing a home kit in the event that they prefer a chew. Cats do not have the option of a treat so they will be sent home with a home kit. *

I DO authorize the use of Oravet with my pet’s dental cleaning today
I do NOT authorize the use of Oravet with my pet’s dental cleaning today

I have been advised as to the nature of the procedures and the risks involved. I realize that no guarantee can ethically or professionally be made regarding the results or cure. I hereby consent to and authorize the performance of the procedures as indicated. I authorize the use of appropriate anesthesia and pain relief medication as needed before, during or after the procedure. Authorization for further procedures may be provided by telephone in consultation with the doctor(s) or staff. I further authorize the performance of any procedures deemed necessary in emergency circumstances on a continual basis until I can be contacted for further instructions. I assume full responsibility for all treatment expenses incurred. Payment in full is due at the time of discharge unless other arrangements have been made. *

I have read, understand, and authorize

Signature of Responsible Party *

Clear Signature

Date *

Dental Procedure Consent Form