Dental Services / Oral Surgery Consent Form

Pet's Name:*

Date:*

Please understand that we will do our best to complete your pet’s dental procedure today. However, oral exams in pets are difficult without anesthesia. In many cases we are unaware of the amount of disease present until a complete exam with x-rays is performed while the animal is anesthetized. If major oral surgery is required we will recover your animal from anesthesia and schedule a second procedure. This will allow us to formulate a treatment plan with you to effectively treat your pet’s dental disease.

Please Read and Initial the Following Services to Accept or Decline.

Pre-anesthetic blood work: This is done to make sure that your pet’s liver and kidneys are functioning well, that he/she is not anemic or dehydrated, and (in our younger pets) to check for congenital problems such as a liver shunt or kidney dysplasia.

Full Chemistry Profile and CBC (included with dental cleaning): *

Accept

Decline

Clindoral Gel Periodontal Treatment (included with cleaning if necessary): Clindoral Gel is indicated for the treatment and control of periodontal disease in dogs. Just one treatment reduces periodontal pocket depth, increases gingival reattachment, and reduces gingival inflammation. We will only apply Clindoral Gel if the veterinarian feels it is necessary.*

Accept

Decline

Antibiotics:Antibiotics will be sent home with all patients demonstrating significant periodontal disease and/or needing extractions. If your pet weighs less than 15 lbs, you may choose antibiotics in liquid or pill form. *

Liquid

Pill

N/A My pet weighs more than 15 lbs.

Digital Radiographs (included with dental cleaning): We recommend dental X-rays for almost every patient. This allows us to evaluate the tooth structure and roots and may reveal underlying dental disease that may not be visible during the initial exam.*

Accept

Decline

Dental Extractions: Extracting teeth requires additional time, instrumentation, and skill . Only the veterinarian will extract teeth. This service is charged by the number of teeth that are extracted. Alternatively, we can refer you to a board-certified veterinary dentist if your pet has a tooth that could be treated with endodontics (e.g. root canal). Please choose from the following options:*

I request that any necessary extractions be done at the discretion of the veterinarian, and I accept the additional charges.

I request to be notified prior to any extractions. I understand that my pet will be under anesthesia longer as I am being notified, and I accept the additional charges. If I cannot be reached at the number I have listed, please

Do proceed with any extractions needed.

Do not proceed with any extractions needed.

I prefer to have my pet referred to a board-certified veterinary dentist for endodontic therapy if a tooth could be saved by this treatment.

Consent: I am the owner/agent for the above animal, and I authorize and request the services listed on this form and/or outlined on the standard dental treatment plan. I am aware that there are certain risks and complications associated with anesthesia, surgery, and medications, even with an apparently healthy animal. I authorize the use of appropriate anesthesia and pain medication as needed before, during, and after the procedure. I understand that hospital support personnel will be used as deemed necessary by the veterinarian. I further understand that I will be charged for flea medication and a dose will be applied if evidence of fleas is found on my pet today.

Please type your name below in acknowledgement of the above mentioned statement.*

Dental Services / Oral Surgery Consent Form

Pet's Name:*

Date:*

Antibiotics:Antibiotics will be sent home with all patients demonstrating significant periodontal disease and/or needing extractions. If your pet weighs less than 15 lbs, you may choose antibiotics in liquid or pill form. *

Digital Radiographs (included with dental cleaning): We recommend dental X-rays for almost every patient. This allows us to evaluate the tooth structure and roots and may reveal underlying dental disease that may not be visible during the initial exam.*

Number where you can be reached today:*

Please type your name to acknowledge this form in its entirety.*

Today's Date: