Dental Procedure Consent

Consent for Anesthesia and Dental

I, the undersigned, am the owner or authorized agent of the pet listed below and am at least 18 years of age. I elect
to have this pet undergo the anesthetic and dental procedure listed below, and declare that I understand the
procedure along with associated benefits and risks (up to and including death) as outlined above, and I have had the
opportunity to have my questions regarding the procedure answered.

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Would you like us to call or text you at this phone number?(Required)

My pet has had food withheld for a minimum of 8 hour:

My pet’s status
My pet’s current medications/supplements:
Last Given

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