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No Anesthesia Dental Consent Form

Date

Owner

Patient

Please choose one of the following options:

Please complete the No Anesthesia dental cleaning completely, EVEN if extractions or any other necessary anesthetic procedure need to be performed at a later date.

Please STOP the No Anesthesia Dental procedure if it is found that my pet needs general anesthesia for extractions or other needs. There would be no charge for stopping cleaning today.

POSSIBLE COMPLICATIONS OF DENTAL CLEANING

* Infection – of the gums, extraction sites, jaw (osteomyelitis) or systemic

* Pain/anorexia (not eating)

* Recurrence of periodontal disease – dependent upon aggressiveness of prevention

* Bleeding of the gums – should resolve within 1-2 days

Untitled checkboxes field

I certify that I am aware of the risks associated with this dental cleaning.

I understand that if any extractions need to be performed, that it will require a separate appointment and performed under general anesthesia with an additional fee.

I understand that my pet must have current vaccines and that any vaccinations done today are at my expense.

No Anesthesia Dental Consent Form

Date

Owner

Patient

Please choose one of the following options:

Do you approve for your pet to receive a sedative (at an additional charge) if needed to help reduce anxiety during this procedure?

I would like to pick my pet up at

Signed Owner/Agent

Best Contact Number