Dental Treatment Consent Form

Vaccinations must be current to stay in the hospital. If your pet has been vaccinated elsewhere, please either bring a copy of the records (or receipt) or upload a copy to us prior to your pet's visit.*

I verify that my pet has had a Rabies vaccination and Upper Respiratory/Distemper vaccination within the last 1-3 years

EXTERNAL PARASITES: Pets found to have fleas or ticks upon presentation will be treated and charged accordingly ($15.00 for pets under 25#, $25.00 for pets over 25#) PRE-ANESTHETIC BLOODWORK Pre-Surgical Lab Testing appropriate to your pet's age and health status has been performed or will be performed prior to giving any medications.

ANESTHESIA: I authorize the use of appropriate anesthetics and other medications. I understand that during this procedure(s), unforeseen conditions may be revealed that necessitate an extension of the same or different procedure(s) than set forth above. I also understand that, despite pre-surgical exams and diagnostics, unforseen conditions may exist that may cause unexpected anesthetic complications. I authorize the Doctors and Staff to do everything within their power to prevent anesthetic complications.

Resuscitative directive

In the unlikely event of Cardiac Arrest, I authorize the following:


In the event that I can not be contacted during my pet's procedure, I authorize the Doctor to perform extractions that are deemed necessary and will only be performed when the Doctor determines that the tooth can not be saved.

Oravet, plaque barrier sealant *

Oravet can be applied after the teeth are cleaned to reduce the build-up of new plaque. This is especially helpful for small breeds and dogs prone to rapid tartar accumulation. Follow up home care, once a week, is important to continue the benefit of this treatment

Other services

I would also like the following procedures performed

Contact information

It is CRITICAL that we have contact information so that you can be reached throughout the day in case of Emergency or the Doctor needing to discuss your pet's condition. Preferred Method of Communication Today:

By Typing my Name Below *

I authorize a Dental Treatment (General anesthesia/ Dental Radiographs/ Dental Cleaning) to be performed on my pet in my absence. I further authorize any other procedures that I have indicated in this document. I have been advised as to the nature of the procedure(s) and the risks involved. I realize that results cannot be guaranteed. I agree to pay for all services rendered at the time of my pet's discharge regardless of outcome.