Dental Procedure Consent Form

If your pet has an upcoming dental cleaning, extraction, or oral surgery at Vet Med Animal Hospital in Lafayette, please complete this consent form before their appointment. Submitting it in advance gives our team the information and authorization needed to move forward with your pet’s dental care.

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Dental Procedure Consent Form

Please complete the form below before your pet’s scheduled dental procedure. Fields include your contact information, your pet’s details, procedure-related preferences, and your authorization for treatment.

Name *

First

Last

Email *

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 ongoing 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 for approval.
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

Signature *

Clear Signature

Today's Date *

Phone

Dental Procedure Consent Form

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Dental Procedure Consent Form

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