Dental Consent Form (Dog/Cat)

Please fill out the form below and press submit. You will get a confirmation email of the information provided.

Owner Information

Primary Contact

Mobile Phone

Work Phone

Email:

Emergency Contact

Emergency Phone (secondary/alternative phone)

Patient Information

Pet's Name

Species

Breed

Age

Color

Sex

Male

Male-Neutered

Female

Female-Spayed

Weight

Thank you for choosing our veterinary hospital for your pet’s surgical needs. The following information will be used to help our veterinary team assess your pet prior to their preoperative exam and surgery.

Has your pet had any food past 8 p.m. last night?

Yes

Has your pet ever had any convulsions or seizures?

Yes

Has your pet ever had an adverse reaction to any medications, vaccines, or anesthesia?

Yes

Not Sure

Is your pet currently taking any medications?

Yes

List all medications

If yes, what time was medication last given

How was it given?

Does your pet have any chronic illnesses/diseases?

Yes

Is your pet current on vaccines and flea & heartworm prevention?

Yes

Do you want your pet microchipped while under anesthesia?

Yes

No - my pet is already microchipped

Your pet has been scheduled for a dental procedure. Under most circumstances, it is not possible to fully assess the extent of a dental procedure. A full oral examination is only possible after the animal has been anesthetized. As a result, we often find unexpected extractions or other issues only after the procedure has begun.

Please choose how you would like us to handle unexpected dental work:

I authorize the attending veterinarian to perform any extractions, x-rays, or procedures deemed necessary while my pet is anesthetized.

Please attempt to contact me prior to any additional procedures are performed on my pet. If you are unable to contact me, I authorize any additional treatment deemed necessary.

Please contact me regarding any additional procedures. If I am not available, DO NOT PROCEED. I understand this will require my pet to undergo anesthesia at a different time and at an additional cost.

AUTHORIZATION: I represent/own the pet listed above and hereby authorize the hospital to perform the above procedure(s). The nature and purpose of the procedure(s) has been explained to me and I understand that no guarantee exists as to the result or diagnosis and treatment of my pet.

I have had the fees outlined to me and agree to pay, in full, all such fees and charges at the time of discharge. These fees and charges may include those deemed necessary for medical or surgical complications or unforeseen circumstances, unless expressly declined previously on the consent form. I also acknowledge, by signing this form that I have read and understand all information included on this form.

I understand that my pet will be placed under general anesthesia or sedated for the necessary procedure and understand that there are inherent risks associated with the use of general anesthesia and sedatives, including acute death.

I understand that Lange Animal Hospital and its employees are properly trained in the administration of sedatives and general anesthetics and will properly monitor my pet during the course of the anesthesia and sedation. I give Lange Animal Hospital and its employees permission to use general anesthesia or sedation on my pet and release them from any liability should an adverse reaction occur. Should an adverse reaction occur, I give Lange Animal Hospital and its employees permission to perform all emergency procedures necessary to attempt to resuscitate and stabilize my pet. Should any problems occur, I can be reached at the phone number listed above.

I, the above signed owner, agent of the owner, or Good Samaritan responsible for seeking veterinary care for the pet identified, certify that I am eighteen years of age or over.

Client Signature

Signature