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DENTAL
CONSENT FORM

Save time during your appointment! Complete your required dental consent form online from any device at any time before your visit.

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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.

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Sex *

Male
Neutered Male
Female
Spayed Female

Age/Date of Birth *

Color *

Weight *

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

Would like a nail trim while under anesthesia.

I understand that if my pet is found to have fleas Central Valley Animal Hospital has the right to treat at my expense. *

I have read and agree the above statement.

BLOOD WORK: It is our job to ensure that your pet can properly process and eliminate the anesthetic he/she is given today. Before we perform any procedure requiring anesthesia, we REQUIRE pre-operative blood work on your pet. With testing, we are able to confirm that your pet's organs are functioning properly and could potentially reveal any hidden health conditions that could put your pet at risk.

Please Choose One *

YES, my pet has already had blood work done.
NO, my blood work needs to be done, in hospital prior to anesthesia today.

CURRENT MEDICATIONS

My pet is currently on the following medications:

These medications where given (date AND time)

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 the above statement.

Owner's Name *

First

Last

Owner's Email *

Owner's Phone No. *

Alternate Phone No. *

Signature *

Clear Signature

Today's Date *

Phone

Online Form

DENTAL
CONSENT FORM

DENTAL CONSENT FORM

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Call us at (360) 930-5142

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