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Dental Consent FormLake Area Animal Clinic

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Dental Consent Form

Client Name *

First

Last

Pet’s Name *

Email *

Under most circumstances it is not possible to fully assess the extent of dental disease in an awake animal. A complete oral examination can only occur after your pet is anesthetized. Following anesthesia a technician will scale, clean and polish your pet’s teeth. We will then examine the teeth and gum tissue which often presents unexpected extractions or other problems that need to be addressed.

The cost associated with extractions can be dependent on complications that can and do occur. Occasionally roots can break during extraction, making the procedure more challenging. Jaw fractures, although rare, can occur in patients who have advanced dental disease that causes bone resorption and jaw weakness. There are some roots that are close to the nasal cavity and sinuses which pose risks for these to be entered during extraction. You may have to be referred, at your expense, to a specialist to handle some of these complications based on our findings.

Please read and authorize the following: *

I have been informed, and fully understand, that cleaning my pet’s teeth is a dental procedure requiring general anesthesia and could potentially involve risks and complications for my pet.
I have been informed that, although rare, complications can occur while administering dental procedure(s) and treatment to my pet. I acknowledge and understand that complications arising from my pet’s dental procedures could include, but are not limited to, infections, broken jaw, allergic reactions to medications, cardiac arrest and possible death.
I have been informed that full extent of my pet’s dental disease cannot be identified until my pet has been anesthetized and the plaque/tarter has been removed. I have been informed that during the exam following the tarter removal it may be discovered that there are conditions that may need to be repaired or require teeth to be removed.

I have been offered Pre-Anesthetic bloodwork at the cost of $89.50. I understand this will be an additional charge not included on my estimate. Pre-Anesthetic bloodwork is used to evaluate my pet’s general health and ability to tolerate anesthesia by checking organ systems. *

I accept
I decline

Please authorize the option below on how you would like us to handle unexpected dental work: *

I give my consent for the veterinarians to use their professional judgement and extract any teeth necessary and will be responsible for those additional costs.
I would like to be contacted before major dental work is done. If I CANNOT be contacted I DO give my consent for the veterinarian to use their professional judgement and extract any teeth necessary and will be responsible for those additional costs.
I DO NOT authorize any additional work today, beyond a scale and polish, without being contacted first. I understand in the event I cannot be reached, we will need to reschedule this additional work at a later date. An additional anesthesia fee will be charged at that time. We can get you a more accurate estimate today for that extra work.

Phone Number where I can be reached today: *

Owner’s Signature *

Date *

Dental Consent FormLake Area Animal Clinic

Dental Consent Form

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