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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.

Pet’s name

Date

Species

Date of Birth

Sex

Male

Female

Surgical/Dental Procedure(s)

The estimated price range for this procedure is between: $

Initial

Client Name:(Required)

Client Signature:

Phone number where you can be reached today:

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

Call

Text

Additional Services

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

Yes

No

My pet’s status

My pet’s current medications/supplements:

Dose

Last Given

Veterinarian Name:

Veterinarian/Technician Signature:(Required)

Date(Required)

CAPTCHA

Name

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

Dental Procedure Consent

Consent for Anesthesia and Dental

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920-722-1518

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920-722-1518