Dental Consent Form

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Claremont Veterinary Hospital Dental Consent Form

Please fill out the form below as accurately as possible!

Name *

First

Last

Email *

Primary Phone *

That can be reached at today

Secondary Phone

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Sex *

Male
Neutered Male
Female
Spayed Female

I, the undersigned owner or agent of the owner of the pet certify that I am the age mentioned below. I have been informed that my pet is in need of preventive or therapeutic dental care and consent to the appropriate procedures described to me by staff veterinarians at Claremont Veterinary Hospital. These procedures include but are not limited to: 1) dental prophylaxes (routine teeth cleaning and polishing), 2) extractions, 3)gingival flap surgery to close gaps left by extractions, 4)root canal procedures, 5)root planning, 6)fillings for cavities, 7) dental radiographs, and/or 8) antibiotic gel implants.I am aware that dental procedures for pets require the use of anesthesia to: 1) maximize visualization of the gums, teeth, and oral cavity, 2) minimize movement and discomfort, and 3) 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 the attending veterinarian before these procedures are initiated. Should unexpected life-saving emergency care be required and the attending veterinarian is unable to reach me, the staff has my permission to provide such treatment and I agree to pay for such care.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. Nevertheless, all questions and concerns I have about the recommended dental procedures have been answered to my satisfaction.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 assume financial responsibility for all fees incurred and agree to provide payment via cash, credit card, or check at the time my pet is discharged. I agreeto pay a monthly billing and financing fee equal to 1.5% of any unpaid balance. *

I have read and accept the financial policy.

Please check one:

I, the owner am above the age of 18.
I, the owner am under the age of 18

PLEASE NOTE: ANY PET ADMITTED WITH EVIDENCE OF EXTERNAL PARASITES (FLEAS, TICKS, ETC.) WILL BE TREATED AT THE OWNERS EXPENSE. VETERINARY SERVICE DURING NIGHTTIME HOURS, SOME DAYTIME HOURS AND/OR WEEKENDS IS PROVIDED AT THE DISCRETION OF THE VETERINARIAN IN CHARGE. CONTINUOUS PRESCENCE OF PERSONNEL MAY NOT BE PROVIDED DURING THES HOURS.

Signature *

Clear Signature

Date / Time

Message

*This promotion is valid for new clients only and may be used once per client. Cannot be combined with other offers or promotions. Other restrictions may apply.

Dental Consent Form

Claremont Veterinary Hospital Dental Consent Form

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