Client Dentistry Consent Form | Richmond Veterinary Clinic

Are there any times you will NOT be able to be reached on the day of the procedure?*

If there is another person you would like to allow to make decisions regarding your pet’s care, please list their full name and relation to you:

Name and relation to you:
Phone Number:

Pet's Name:*

Species:*

Canine

Feline

Age or DOB:*

Sex:*

Male

Female

Male/Neutered

Female/Spayed

Date of the Procedure*

What medications is your pet taking? Please include:
Drug Name & Strength
Dose
Frequency
Last Given
Need refill?*

I am the owner or agent for the animal described above and I have the authority to execute this consent. (Initial)*

Please Choose ONE:*

I approve all medically recommended dental extractions and accept financial responsibility for associated costs.

I would like to be contacted by the front desk team before any dental extractions are performed. I understand that if I cannot be contacted within 5 minutes, that the extractions will not be performed and that a future procedure may have additional associated costs.

I understand that it is important to keep my phone on and accessible during the day of the procedure in order to communicate with Richmond Veterinary Clinic about my pet’s care. I understand that for the safety of my pet, the doctor performing the dental cleaning will not be available to discuss my pet’s care during the procedure but will meet with me during my discharge appointment.*

(Initial)

Dental extractions are performed based on medical necessity due to decay or disease located underneath the gumline that may not be visible without the use of dental X-rays. I understand that dental X-rays are taken during my pet’s procedure, meaning need for extraction may be determined during the procedure and are an additional cost per tooth, and cost varies depending on tooth type. I understand that approving all necessary dental extractions will include extractions discovered while my pet is under anesthesia, and will incur additional costs not included on my estimate.*

(Initial)

This healthcare plan was prepared based on our assessment of your pet's needs. Because the needs of your pet can change quickly, this plan is only valid for 30 days.*

(Initial)

All patients requiring general anesthesia and anesthetic dental procedures will receive, at a minimum: IV catheterization, IV fluid therapy, injectable and/or inhalant anesthesia, endotracheal intubation, electronic monitoring, complete oral radiographs, ultrasonic scaling and dental polishing, and body heat maintenance support.*

(Initial)

Complications of this procedure include, but are not limited to: Hypotension, hypothermia, hypoxia, cardiac arrhythmias, compromise to the airway, bleeding, incision failure, infection at the surgical site, adverse drug reactions, bruising, IV catheter failure, leakage at the IV catheter site, aspiration pneumonia, fractured jaw, oral-nasal fistula formation, retained dental roots, extraction surgical site dehiscence. I understand that while rare, there are risks associated with this procedure.*

(Initial)

Home dental care is recommended following your pet's recovery from their dental procedures. These options include brushing, oral wipes, food additives, water additives, treats and other modalities. I acknowledge this recommendation and understand these options.*

(Initial)

The nature of the procedure has been explained to me, and I understand what will be done. I have asked and had answered any questions I have related to the procedure, the safety of the procedure or that of any potential complications. I accept all of the risks associated with this procedure. I authorize the use of appropriate anesthesia and pain relief medication as needed before or after the procedure. I understand that hospital support personnel will be used as deemed necessary by the veterinarian.*

(Initial)

I do hereby consent and grant the veterinarians of Richmond Veterinary Clinic and all of their employees, agents, servants, and/or representatives (collectively, the “Hospital”) full and complete authority to perform the surgeries, procedures and treatments described above and to provide any ancillary care, and to perform any other procedure or treatment that, at the veterinarian’s discretion, may be deemed medically necessary for my pet; and I do hereby forever release and discharge the Hospital from any and all liability arising from such procedures and treatments. I have read and understand this estimate. I agree to pay, in full, for services rendered at the time of service (including those deemed necessary for medical/surgical complications or unforeseen circumstances).

I understand that care may be required following the discharge of my pet. I agree to follow and perform all instructions given to me for this care, as outlined in the discharge instructions which will be provided by Richmond Veterinary Clinic. I understand that it is my responsibility to contact the veterinarian if I have any questions or concerns regarding my pet's recovery.*

Client Signature:
Date:
Employee Signature:
Date:

Dentistry Consent Form

Are there any times you will NOT be able to be reached on the day of the procedure?*

If there is another person you would like to allow to make decisions regarding your pet’s care, please list their full name and relation to you:

Pet Information

Pet's Name:*

Species:*

Age or DOB:*

Sex:*

Anesthetic Dental Procedure Information:

Date of the Procedure*

What medications is your pet taking? Please include:
Drug Name & Strength
Dose
Frequency
Last Given
Need refill?*

I am the owner or agent for the animal described above and I have the authority to execute this consent. (Initial)*

Please Choose ONE:*

PLEASE READ

This healthcare plan was prepared based on our assessment of your pet's needs. Because the needs of your pet can change quickly, this plan is only valid for 30 days.*

Home dental care is recommended following your pet's recovery from their dental procedures. These options include brushing, oral wipes, food additives, water additives, treats and other modalities. I acknowledge this recommendation and understand these options.*

Dentistry Consent Form

Are there any times you will NOT be able to be reached on the day of the procedure?*

If there is another person you would like to allow to make decisions regarding your pet’s care, please list their full name and relation to you:

Pet Information

Pet's Name:*

Species:*

Age or DOB:*

Sex:*

Anesthetic Dental Procedure Information:

Date of the Procedure*

What medications is your pet taking? Please include: Drug Name & Strength Dose Frequency Last Given Need refill?*

I am the owner or agent for the animal described above and I have the authority to execute this consent. (Initial)*

Please Choose ONE:*

PLEASE READ

This healthcare plan was prepared based on our assessment of your pet's needs. Because the needs of your pet can change quickly, this plan is only valid for 30 days.*

Home dental care is recommended following your pet's recovery from their dental procedures. These options include brushing, oral wipes, food additives, water additives, treats and other modalities. I acknowledge this recommendation and understand these options.*

What medications is your pet taking? Please include:
Drug Name & Strength
Dose
Frequency
Last Given
Need refill?*