Oral Health Assessment And Treatment Consent Form
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1Oral Health Assessment and Treatment Consent Form
Name of Pet:
Doctor:
Client:
Date:
I understand my pet will be placed under general anesthesia for the following procedures:
•
Complete Oral Exam
•
Dental radiographs to further evaluate the teeth and supporting structures.
•
Cleaning of the teeth, sub-gingival cleaning, and polishing of the teeth.
I understand it is impossible to know if my pet will need additional treatments (including
extractions, oral surgery, and/or special periodontal therapy) prior to the above procedures. I
understand I will be contacted by phone after my pet's complete oral assessment to discuss
the treatment plan needed including a new cost estimate and potential complications.
Should we NOT be able to reach you by phone (please check one box):
If I cannot be reached by phone, I authorize the veterinarian to proceed with all
necessary treatments, including extractions. I understand I am fully responsible for any
additional costs for these procedures.
If I cannot be reached by phone, I do NOT authorize any additional treatments. I ask
that you wake my pet with the understanding we may need to return for additional treatments
under general anesthesia at a later date.
Phone number I can be reached at today:
*NOTE: This number is for IMMEDIATE contact since your pet will be under general
anesthesia and timing is critical."
I have read and understand the following in regards to general anesthesia and oral
surgery:
I understand my pet will undergo general anesthesia today. Risks of general
anesthesia, including death, have been explained to me. I understand there can be
complications, although rare, with any anesthetic or surgical procedure. I understand my pet
will not be under general anesthesia longer than two (2) hours, which may entail a second
dental procedure should my pet require extensive treatment.
I understand my pet may need additional therapies today, including extractions. Rare
complications associated with extractions include infection, wound dehiscence, incomplete
extraction/retained roots, jaw fracture, excessive bleeding and orbital trauma.
I understand alternative treatment (i.e. root canal therapy) may be recommended
today. I understand advanced or complicated treatments will necessitate referral to a dental
specialist, which will require an additional procedure at a later date. I understand it is my
option to decline these services.
Date
Owner Signature
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