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Dental Procedure Consent Form

A free fillable dental consent form for veterinary use, with radiograph and extraction elections recorded before the anaesthetic. Sign on screen, then print or save as a PDF. Patient and owner details are never stored or sent anywhere.

Admission

Admission Details

Client

Client's Details

Patient

Patient's Details

Procedure

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.

Full-mouth dental radiographs

(the only way to assess below the gumline)

I authorise extractions the veterinarian judges necessary based on the examination and radiographs

(e.g. authorised extraction count or cost cap, existing conditions, medications given today)

Consent

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 signature
Staff signature
Preview

Dental Procedure Consent Form

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Dental Procedure Consent Form

Admission Details

Date of admission
Time of admission

Client's Details

First name
Last name
Best contact number today
Email

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

Built by Dr Duncan Houston for Ask A Vet · askavet.com

Nothing typed into this form is sent to or stored by askavet.com. All data stays in your browser and leaves only in the PDF or printout you create. This template is general in nature. Check the consent and record-keeping requirements of your local veterinary regulator, and adapt the wording to your practice with your own adviser where needed.

Dr Duncan Houston
About the author

Dr Duncan Houston · BVSc, Veterinarian

Emergency careGeneral practiceMobile vet careFounder, ASK A VET™

Dr Duncan Houston is an Australian veterinarian with experience in emergency, general-practice and mobile veterinary care. He is the founder of ASK A VET™. This guide is educational and is not a substitute for hands-on veterinary care.

When Remember is on, this page saves your clinic's details in this browser only. Owner and patient details are never saved. It is never sent to Ask A Vet. Use Forget to remove them from this computer.