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Dental Procedure Consent
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
MM slash DD slash YYYY
Species
Date of Birth
MM slash DD slash YYYY
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
Add
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Veterinarian Name:
Veterinarian/Technician Signature:
(Required)
Date
(Required)
MM slash DD slash YYYY
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Name
This field is for validation purposes and should be left unchanged.
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920-722-1518
417 N. Tullar Road,
Neenah, WI 54956
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