I, the undersigned owner, or owner’s authorized agent, of the above pet certify that I am over eighteen (18) years of age. I have been informed that my pet is in need of preventive or therapeutic dental care and hereby consent to the appropriate procedures described to me by staff veterinarians at this facility. These procedures include but are not limited to the following: dental prophylaxis- routine teeth cleaning and polishing, extractions, oral surgery to close gaps left by extractions, root canal procedures, root planings, fillings for cavities, dental x-rays, orthodontic work, and antibiotic gel implants.

I am aware that dental procedures for animals require the use of anesthesia to: maximize visualization of the gums, teeth, and oral cavity, minimize movement and discomfort, and provide for the safety of the pet, doctors, and hospital staff. I understand that some risks always exist with anesthesia and dental procedures and that I am encouraged to discuss any concerns I have about those risks with my attending veterinarian before these procedures are initiated. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made.

I have been informed that examinations under anesthesia often reveal abnormally loose teeth that fall out or should be extracted to prevent oral discomfort and ongoing infection of surrounding bone. I also have been informed that the loss or removal of one or more unhealthy canine teeth occasionally allows for an awkward protrusion of the tongue to one side or the other. I understand that a staff member will attempt to contact me for information about and authorization for treatment recommendations, including if any extractions are necessary.

If I cannot be reached while my pet is undergoing anesthesia and dental care, I understand that the additional recommended services will NOT be performed and this will require a second anesthetic procedure if I opt to have those performed another day. Otherwise, all questions and concerns I have about the recommended dental procedures have been answered to my satisfaction.

I understand it is a hospital policy to perform pre-anesthetic blood work on my pet prior to any sedation or anesthesia today and that if there are any abnormalities which are determined to make an anesthetic procedure unsafe today, I am responsible for paying the cost of the bloodwork at the time my pet is discharged.

I understand that an estimate of the fees for the above dental care will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered. I agree to pay 100 % of the estimated fees, assume financial responsibility for the balance of services rendered, and agree to provide payment on a cash, credit card or check basis at the time my pet is discharged.