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We place the highest priority on ensuring you feel comfortable with the plan for your pet’s care and fully understand the authorizations below before giving your consent. If you have any questions or need clarification on any of the choices, please contact the hospital so a medical team member can review the form with you prior to completing it. As always, thank you for entrusting us with your pet’s care.

Appointment Date*

Appointment Time*

AM/PM

Client's First Name*

Client's Last Name*

Phone*

Email*

Pet's Name*

Species*

Canine

Feline

Your pet is scheduled for a dental cleaning, polishing, oral health exam, and digital dental x-rays. A full mouth exam will be completed once heavy tartar has been removed. The veterinarian(s) may discover teeth that are fractured, decayed, abscessed or loose after performing the full mouth exam and dental x-rays. in many cases, extractions are recommended to prevent pain, infection, and/or future dental complications.

Consent*

I have read and authorize

I hereby consent that the dental treatment/procedure identified above has been explained to my satisfaction by the veterinarian and that there can be no guarantee as to the outcome of any procedure/dental treatment.

Consent*

I have read and authorize

I hereby authorize anesthesia/dental treatment for my pet. While Health and Harmony provides the highest quality of anesthesia monitoring and surgical services, I understand that there are inherent risks associated with any surgical procedure, even in apparently healthy animals. I have been advised that there is risk of complications and in the rarest case, even death. I will not hold Health and Harmony liable for any complications that may arise.

Please select one of the following options*

I authorize the Veterinarian(s) to extract any teeth that in his/her professional judgement are not sound, appear infected, or may be causing pain. I do not need to be contacted should these procedures cause the final cost of the procedure to be higher than the signed estimate.

I request the Veterinarian(s) contact me if is deemed necessary to perform any extractions, that in his/her judgment are not sound, appear infected, or may be causing pain. If I cannot be reached, I give permission for any needed extractions. These procedures may cause the final cost of the procedure to be higher than the signed estimate.

I request the Veterinarian(s) contact me before ANY extractions are performed. If I cannot be reached, do NOT perform any extractions. This may mean your animal will need another anesthetic procedure in the future to remove the diseased teeth.

In the event of an unforeseen emergency, if your pet were to go into cardiac or respiratory arrest, please indicate what life-saving measures you would like the doctors and medical staff to take by selecting ONE choice below

Please attempt resuscitation by performing CPR (cardiopulmonary resuscitation). Life-saving measures may include, but are not limited to, external chest compressions, securing an airway, giving oxygen, placing an IV catheter, and administering any necessary drugs. I understand that there are additional costs associated with life-saving measures and that resuscitation is not appropriate for every patient that has gone into cardiac arrest

Please DO NOT perform life-saving measures.

Signature*

Date*

Name

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What's Next

1
Call us or schedule an appointment online.
2
Meet with a doctor for an initial exam.
3
Put a plan together for your pet.

Make An Appointment

Dental Consent Form

What's Next

Call us or schedule an appointment online.

Meet with a doctor for an initial exam.

Put a plan together for your pet.

Where family pets find loving care