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Dental Consent Form

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Client First Name*

Client Last Name*

Patient Name*

Phone*

Procedure*

I, the undersigned, certify that I am the owner, or authorized agent for the owner, of the
animal listed above. I authorize the Veterinarian(s) and staff of Strong Veterinary
Hospital to perform the procedure(s) listed above and/or on the estimate for my animal. I
authorize the use of anesthesia and other medication as deemed necessary by the
veterinarian and understand that hospital personnel will be employed in the procedure(s)
as directed by the veterinarian.

I have been informed that a routine Dental Prophylactic procedure consists of removal of
tartar(calculus), scaling the surface of each tooth, polishing the teeth. A comprehensive
oral examination under anesthesia may detect further periodontal disease problems by
measuring for pockets, and dental calculus hiding underlying cavities or fractures. When
any of a pet’s teeth cannot be treated or repaired to a healthy, comfortable, and
functional condition, the normal procedure is removal(extraction) of these teeth. I
understand that generally the amount of damage to pet’s teeth varies from minor to
extreme, and usually cannot be evaluated accurately until the pet is under anesthesia
and the teeth are clean.

If further dental problems are detected while your pet is under anesthesia, please select ONE Option below regarding how we will proceed with these dental problems:*

Perform any necessary extractions at this time. I understand my pet will be started on antibiotics and pain medication. I agree to assume financial responsibility for these additional charges.

Call me after the dental exam and provide an estimate of any additional procedures. I understand that if I cannot be contacted at the above number, necessary extractions will be performed, and my pet will be started on antibiotics and pain medication. I agree to assume financial responsibility for these additional charges.

Call me after the dental exam and provide an estimate of any additional procedures. Do not proceed without authorization. I understand that if I cannot be contacted at the above number, no extractions will be performed, and I assume all responsibility for any complications this decision may cause for my pet. I also understand that if I decide to have these additional services done later, I have to schedule for a different appointment with separate charges.

I have read and understand this form and accept responsibility for payment of all
charges incurred and services provided to my animal by Strong Veterinary Hospital.

Signature*

Date*

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Dental Consent Form

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