Dental Consent Form - Patient Medication And Allergy History printable pdf download

Client Name: __________________________________

Dental Consent Form

Patient Name: __________________________________

Patient medication and A llergy H istory

Is your pet currently taking any medications or over the counter supplements?

YES

If yes, please list the all prescription and over the counter medications and current dose:

_______________________________________________________________________________________________

Does your pet have any allergies?

YES

If yes, please list all known allergies___________________________________________________________________

E xtraction Consent

Your pet is being admitted for a comprehensive oral health assessment and treatment. This is a rough estimate of the

expected expenses for your pet based on the initial visual exam. It is good for 30 days. Sometimes with dental disease,

problems that are present may not be revealed until a thorough exam under general anesthesia is performed. Dental

radiographs are utilized to assess disease below the gum line during this exam. Since it is difficult to predict the extent of

disease process on a rough visual exam, variations in cost may occur. In cases where further work is required and further

expenses may result, every attempt will be made by the doctor to contact the owner, to discuss the case. If contact cannot

be made at the phone numbers provided within 15 minutes and the nature of the procedure is deemed an emergency, a

decision may have to be performed without prior notification. If the procedures are of a non-emergency nature (non-life

threatening), and

professional judgment, I prefer the following:

Dental procedures, including simple and surgical extractions can be associated with risks. I understand these risks may

include broken tooth roots, bleeding, dry sockets, and damage to surrounding tissues. Rarely, fractures of the bone may

occur, necessitating further work. At our hospital, every effort is made to predict and avoid these complications but

unforeseen events may occur.

Have the doctor proceed with all procedures, including unforeseen tooth extractions as determined by the attending

doctor.

Have the doctor proceed with all procedures, including unforeseen tooth extractions, up to $ ________ cost. Please

call to discuss the case if more work is needed beyond this cost. If I am unable to be reached, only part of the needed

work will be done and the procedure may be finished at a later date. This will increase the total cost of the work.

Call me if any additional work, including unforeseen tooth extraction, is needed. I understand that if I cannot be

reached, no additional work will be performed and may have to be completed at a later date. This will increase the total

cost.

I prefer my pet be referred to a board certified Veterinary Dental Specialist and do not authorize any extractions.

Dental Radiograph Consent

I understand that disease below the gum line involving the tooth roots and all surrounding tissues cannot always be

assessed without dental radiographs. The fee for Dental Radiographs is $84.00-$126.00 depending on how many views

are necessary.

I authorize the attending doctor to proceed with dental radiographs as deemed necessary.

I do not authorize any dental radiographs.

Call before dental radiographs are done.

Dental Consent Form - Patient Medication And Allergy History