Dental Consent Form

Dental Consent Form
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Client Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Pet Name
Species
Breed
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Age
Sex
I agree to make myself available by telephone during the approximate time interval of 9:00am to 1:00pm.
Pre-Anesthetic Blood Test
We will perform a full physical examination on your pet before anesthesia. However, not all health issues are apparent on physical exam. Pre-anesthetic blood work is performed to detect any infection, anemia, or problems with organ function (such as liver or kidney problems). For this reason it is required for all patients. Results are immediately available and you will be notified in the event of abnormal results. I have read and understand
Dental Extractions and Minor Dental Surgery

It can be difficult to predict if teeth need extraction when an animal is awake because tartar and movement interfere with the assessment. Severely diseased teeth can cause considerable pain and discomfort and are a source of infections for other organ systems (liver, kidney, lungs, and heart). During the dental cleaning, the teeth are evaluated, and if found to be diseased, they may require an extraction or referral to a veterinary dentist for repair. The cost of extractions varies depending on the difficulty and can range from $36 to $240 per tooth.
In the event that dental extractions, minor dental surgery, or any other procedures are discovered to be necessary during my pet’s dental cleaning, I authorize the following: PLEASE CHOOSE ONE STATEMENT.
DENTAL RADIOGRAPHS: X-rays are vital in the evaluation of your pet’s dental health to allow detection of problems that cannot be seen during an oral exam, as well as an aid in making treatment strategies and to evaluate treatment outcomes. We perform full oral radiographs on all cases. I have read and understand
ORAVET DENTAL SEALANT: Oravet is a dental sealant product recommended by the Veterinary Oral Health Council (www.VOHC.org). Oravet binds electrostatically to tooth enamel, creating an invisible barrier that helps prevent plaque-forming bacteria from attaching. It has been proven to significantly reduce the formation of plaque and calculus.
Emergency Contact Phone
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
I have read and understand this authorization.
Should be Empty:

August	2026
August 2026
SSunday	MMonday	TTuesday	WWednesday	TThursday	FFriday	SSaturday

August›‹	2026»«
August 2026
SSunday	MMonday	TTuesday	WWednesday	TThursday	FFriday	SSaturday
26	27	28	29	30	31	1
2	3	4	5	6	7	8
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16	17	18	19	20	21	22
23	24	25	26	27	28	29
30	31	1	2	3	4	5
6	7	8	9	10	11	12

August›‹	2026»«
August 2026
SSunday	MMonday	TTuesday	WWednesday	TThursday	FFriday	SSaturday
26	27	28	29	30	31	1
2	3	4	5	6	7	8
9	10	11	12	13	14	15
16	17	18	19	20	21	22
23	24	25	26	27	28	29
30	31	1	2	3	4	5
6	7	8	9	10	11	12

Dental Consent Form

Pre-Anesthetic Blood Test

Dental Extractions and Minor Dental Surgery