A person's hand brushes the teeth of a small dog with a blue toothbrush and white and blue toothpaste. The dog is licking the toothbrush.

Dental Procedure Consent Form

Complete this form before your pet’s scheduled veterinary dental procedure at Crown Pointe Animal Hospital in Orléans. It explains anesthesia, full-mouth dental X-rays, possible extractions, emergency authorization, treatment estimates, and the information our team needs before your dog’s or cat’s appointment.

Review and Submit Dental Consent

Provide complete information about medications, allergies, feeding, and emergency contacts. Please remain available by phone while your pet is under anesthesia. If you have questions about the procedure, estimate, or required deposit, contact Crown Pointe Animal Hospital.

Name *

First

Last

Email *

authority me the

Pet's Name *

Emergency Phone Number *

A dental exam can help us understand your pet’s oral health and aspects of your pet’s overall health. However, a thorough exam of your pet’s mouth, teeth and gums cannot be accomplished without the use of anesthesia. In order to minimize the time that your pet is under anesthesia, it is important that we have clear instructions from you in advance with respect to how you would like us to treat any condition that we may discover during the dental exam.

Please Choose One *

Proceed with any procedure you deem necessary to treat any condition you identify during the dental exam, including any treatment to minimize any pain my pet may experience in the future from on-going dental disease.
Proceed with any procedure you deem necessary to treat any condition you identify during the dental exam, but do not exceed my written estimate without contacting me first.
Do not proceed with any procedure without contacting me first.
Other

I am the owner (or authorized agent of the owner) of the animal described above, and have the authority to execute this consent. I understand that some risk always exists with anesthesia, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian and understand that it may be necessary to provide additional medical or surgical treatment to my pet in the event of unforeseen circumstances. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. Subject to my directions above, I hereby authorize the use of anesthetics and other medications, as well as any such additional treatment, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read, and fully understand, this consent. *

I have read and understand

The fees associated with these services have been explained to me, and I agree to pay such fees in full at the time my pet is released from the hospital. *

I have read and agree

Today's Date *

Dental Procedure Consent Form

Review and Submit Dental Consent

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