Dental Surgical Consent Form

Owner's Name*
First Last
Pet's Name*
Date*
MM slash DD slash YYYY
Pet's Breed*
Sex*
- Male
- Female
Pet's Age*
Owner's Email*
Emergency Phone*
Vaccines Current?*
- Yes
- No
Has patient been given aspirin in the last 7-14 days*
- Yes
- No
Was food or water given after 10:00 PM?*
- Yes
- No
*Important*
If my pet has a serious illness or injury, and in the event such illness or injury becomes critical during my absence, I want the doctors and medical team to:*
- Resuscitate my pet
- Do not resuscitate my pet
*
I also authorize Abell Animal Hospital to perform such diagnostic, therapeutic, and surgical procedures that are in their opinion necessary and advisable to maintain my pet’s health. Including, but not limited to the administration of anesthesia, and the services involving pathology and radiology. The nature of such services has been explained to my satisfaction and I accept all procedures to be done to the best of the abilities of the hospital staff. I realize that no guarantee or warranty has ethically or professionally been made regarding the results or cure. I acknowledge that my pet will be discharged only during regular office hours, when doctors, technicians, and receptionists are present. It is understood that the actual cost may exceed the estimated amount. Payments will be completed in full at time of release.
Dental Information
Please note that at the time of dental cleanings we complete an examination of the mouth under anesthesia. This is done after teeth have been scaled (cleaned) to remove calculus accumulation. During this examination we can better determine the need for teeth to be extracted. We ask that you indicate to us whether or not we have your consent to extract diseased or injured teeth. This ensures that we proceed with the necessary treatments as you see fit for your pet in your absence. Please take the time to indicate your preference below, (PLEASE CHOOSE ONE ONLY) and ask us before leaving today if you have any additional questions or concerns.
I approve
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
Call me after the dental examination and provide an updated estimate of any additional procedures. I understand that if I cannot be contacted at the number provided below, 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.
Contact phone for approval
I don't authorize, unless approved
Call me after the dental examination and provide an updated estimate of any additional procedures. Do not proceed without my authorization. I understand that if I cannot be contacted at the number provided below, 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 will have to schedule a different appointment with separate charges.
Contact phone for approval
*I grant Abell Animal Hospital permission to post my pet’s picture, story and medical information on social media
*I grant Abell Animal Hospital permission to send text message updates to my cell phone number (carrier charges may apply)
Please provide cell phone for text messages
Signature*
Date*
MM slash DD slash YYYY
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

Dental Surgical Consent Form

*Important*

Dental Information

Important