Dental Consent Form

Questions

Name*

First Last

Pet's Name*

Phone Number*

Additional Services

Current Meds and Date/Times Last Received:*

Has your pet had food this morning?*

Yes
No

Has your pet had a reaction to anesthesia in the past that you are aware of?*

Yes
No

Procedure

Your pet will undergo general anesthesia for an oral health exam and dental cleaning and polishing. There are inherent risks to anesthesia including death. A physical exam and blood work will be performed this morning. Surgical monitoring equipment will be used to monitor blood pressure, temperature, heart rate and rhythm during the procedure.

An IV catheter will be placed to administer anesthetic agents and fluids, which will require us to shave hair. The oral health exam may identify pathology not visualized in the awake patient such as fractured teeth, periodontal disease, resorptive lesions, abscesses and oral tumors. Any findings may require additional procedures such as x-rays and tooth extractions, which are added expenses.

Risks associated with extractions include broken tooth roots and bleeding. X-rays are necessary to identify pathology below the gum line involving roots and surrounding tissue.

I elect to:

Perform full mouth x-rays (additional $150)
Do not perform dental x-rays

I request that MVP:

Perform any extractions and x-rays deemed medically necessary
Does not perform any additional procedures if I cannot be reached
Proceed within the below total budget if I cannot be reached:

Select a budget

<$500
$500-$1,000
$1,000-$1,500

I authorize the procedures outlined above. I understand that anesthesia always involves risk and that unforeseen conditions may be revealed that necessitate a variance in the treatment plan. I am aware that unforeseen complications resulting from the procedures will not relieve me from any obligations to all reasonable costs incurred regarding the animal. I assume responsibility for all charges incurred in the care of this animal and these charges will be paid at the time of my pet’s release.