Dental Procedure Consent Form
Admission Details
- Date of admission
- Time of admission
Client's Details
- First name
- Last name
- Best contact number today
Patient's Details
- Name
- DOB (age)
- Microchip
- Weight (kg)
- Gender
- Species
- Breed
- Fasted from (date / time)
Dental Procedure & Elections
A complete dental assessment is only possible once your animal is anaesthetised and dental radiographs are taken. Disease below the gumline is invisible on a conscious exam, so the treatment plan, the number of extractions and the cost can all change once the mouth is properly assessed. Your elections below tell us how to proceed when that happens.
- Planned procedure
- Estimated cost from ($)
- Estimated cost to ($)
- Full-mouth dental radiographs
- I authorise extractions the veterinarian judges necessary based on the examination and radiographs
- Contact me during the procedure
- Notes
Consent
I consent to the administration of sedation and/or general anaesthesia to the animal described above and to the dental procedure listed, together with extractions and related treatment in line with my elections above. I understand that anaesthesia and dental surgery carry risks, including adverse drug reactions and, in rare cases, death, even in apparently healthy animals, and that possible complications of extractions include retained roots, oronasal communication and, particularly in small breeds, jaw fracture, which have been explained to me where relevant. I understand that the treatment plan and cost may change once my animal is assessed under anaesthesia, and that I will be contacted in line with my elections above. I confirm that the fasting instructions given to me have been followed. I acknowledge that the estimate above is an estimate and not a fixed quote and that all fees are payable at discharge. I confirm that I am over the age of 18 years and am the owner, or an authorised agent of the owner, of this animal.
- Owner / agent name
- Date signed
Owner / agent signature
- Admitting staff member
- Role
Staff signature