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Dental Procedure Consent Form

Authorize dental procedures confidently. Our dental procedure consent form ensures clarity, compliance, and informed decisions for a seamless dental experience.

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Dental Procedure Consent Form Franklin, WI

Kindly complete the dental procedure consent form accurately. Your precise information ensures a smooth process and well-informed decisions during your dental procedure.

Please read all the information listed below. After reading the dental procedures, please proceed to complete the Dental Consent Form. This form requires a signature and an emergency phone number.

PRE-DENTAL EXAM

Our pre-dental exams are performed prior to your pet’s scheduled dental procedure date.

At this appointment,t an examination of your pet is done, requirements for the procedure are updated, and a comprehensive blood work profile is completed.

Exam: Ear-to-tail exam addressing any concerns you may have as well as recommendations by our veterinarian
Requirements:
- Canine:
  - Rabies Vaccine
  - DAPP (Distemper vaccine)
  - Bordetella Vaccine
  - Heartworm Test – (pet’s over 1 year of age)
- Feline:
  - Rabies Vaccine
  - FVRCP (Distemper vaccine)
Comprehensive Blood Work Profile: Blood work is drawn and sent out to our lab for testing, looking for any levels that may affect the safety of anesthesia or the pet’s health. This blood work panel is valid for 30 days.

EVENING PRIOR TO THE PROCEDURE

Fasting: Your pet will need to be fasted (withholding food) the night before the procedure to ensure an empty stomach. This is important for anesthesia safety.

Remove and do not give any food (including treats) no later than 11 pm the night before the procedure.
Do not give any food or treats on the morning of the procedure
Water is okay to give through the night; however, please withhold water first thing in the morning.

MORNING OF THE PROCEDURE

Check-In: Dental check-in times are scheduled between 8:00 am and 9:00 am.

Please arrive at the practice at your scheduled Check-In time
Please make sure when bringing in your pet they are restrained either by a leash or in a secure carrier
Bring along a small amount of your pet’s regular diet from home
Expect to spend 5 -10 minutes during check-in as the staff will complete the following;
- Review of the signed dental consent form & emergency contact number
- Verification of the procedure taking place & current weight check of your pet
- Address any questions and concerns you have regarding the procedure

POST-OP PHONE CALL

After the procedure, as your pet is in recovery, our doctor or surgery assistant will call/text you with an update on your pet. At this time, your discharge time will be scheduled/confirmed, and any questions you have may be answered.

DISCHARGE PROCEDURE

A discharge time is scheduled for your pet at the time of check-in or adjusted during the Post-Op update.

Please arrive at the practice during your scheduled discharge time
Expect to spend 10-15 minutes during discharge as the staff will complete the following:
- Invoicing and payment of services
- Home Care Instructions – explained by one of our assistants.
- Release of your pet

Complete Form

Dental Procedure Consent Form

Owner's Information

"*" indicates required fields

Name(Required)

First Last

Email(Required)

Pet's Information

Pet's Name(Required)

Breed(Required)

Age(Required)

Date of Scheduled Dental(Required)

MM slash DD slash YYYY

Does your pet need any additional services today? (please select all the apply.)

Microchip

Ear Cleaning

Anal Gland Expression

Simparica

Simparica TRIO

Does your pet have any current medical conditions (vomiting, diarrhea, coughing, sneezing, etc) the doctor should be aware of? If YES, please describe:(Required)

Is your pet currently taking any medications or supplements? If YES, please list:(Required)

Qty:(Required)

Requirements for Dental Procedure(Required)

Rabies Vaccination: Is required for pets over 16 weeks of age

IV Fluids: SQ fluid therapy is administered for anesthesia safety. (a small area will be shaved for IV catheter)

Pre-Op Blood Work: Is required for scheduled dental procedures

I have read, understand, and agree

By checking the box below, I certify my pet has been fasted for this procedure and has not had any food after 11pm the evening before or this morning.(Required)

My pet HAS fasted for this procedure as directed in my pre-surgical instructions.

My pet HAS NOT fasted as directed.

Sedation/Anesthesia(Required)

As with all anesthetic, medications, treatment and/or surgical procedures, I understand there are inherent risks. I acknowledge that the staff/veterinarian has explained the procedures to me, answered questions/concerns to my satisfaction and cannot be held responsible for any unforeseeable results. I authorize the use of appropriate anesthesia and pain relief medication as needed before, during or after the procedure. I further understand that during the course of the procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian.

While I accept that all procedures will be performed to the best of the abilities of the staff/veterinarians, I understand that veterinary medicine is not an exact science and that no guarantees have been made regarding the outcome is this/these procedures. Further, I understand that I am financially responsible for all costs incurred during surgery, treatment and hospitalization and that payment is due at the time of discharge.

I have read, understand, and agree

CPR(Required)

In the event that Testing should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitative ef orts to be initiated until you can be contacted further and notified of Testing 's status? By consenting to this service, you are also acknowledging that certain fees will apply and there is no guarantee to the outcome of these measures.

If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion.

Please select an option on the following field.

I have read and agree

Although not anticipated, should unexpected life-saving emergency care be required I would like the hospital staff to attempt the following life saving measures.(Required)

CPR, Cardiopulmonary Resuscitation

DNR, Do NOT attempt Resuscitation

By consenting to this service, you are also acknowledging that certain fees will apply and there is no guarantee to the outcome of these measures. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion.

Authorization(Required)

I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatments, results or cures. I accept that my financial obligations remain regardless of the outcome and understand fees must be paid upon release of my pet from the practice.

I have read and understand this authorization and hereby accept and agree to the terms of the consent for treatment.

I hereby certify I am the owner/authorized agent for the owner and have the full authority to execute this consent and except full financial responsibility.

I have read and agree

Signature of Owner/Agent(Required)

I have read and understand this authorization and hereby accept and agree to the terms of the consent for treatment.

Today's Date(Required)

MM slash DD slash YYYY

Phone(Required)

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.

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