Dental Consent

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Animal Medical Care Center
2816 George Washington Memorial Hwy Yorktown, VA 23693 (757) 867-8808
Dentistry Consent Form
Please take a moment to read and complete this form so we can give your pet the best possible veterinary care.
Pet's Name: _______________________________ Date: ____________________
Procedure to be performed:________________________________
Any special problems you want the doctor to examine:___________________________________________________ Please list the medications your pet is currently taking, the dosage and when they were last
given:____________________________________________________________________________________________ When was the last time your pet ate?__________________________________________________________________
Has your pet ever had an adverse reaction to any medication or anesthesia? Yes ( ) No ( ) If yes, please
explain:__________________________________________________________________________________________
Class IV laser therapy is the use of a beam of laser light directed into tissues to increase blood flow, reduce pain, decrease
inflammation & promote healing from surgical procedures. Would you like your pet to receive laser therapy today for an additional
W$e1m5.a0y0 i?denYteifsy(a)ddiNtioon(a)l problems during the dental prophylaxis that could not be appreciated beforehand such as broken or abAscfelsesaed&tteiectkht,rdeaeetmpepnotcwkieltlinbeg,abpopnlie dloasts,thgeroowwtnhesr'isnetxhpeemnsoeuttoh,acnayrpieest,tehtact. tThheevseeteprrinobarleiamnsoarraesbsiessttandteanlottwesitfhlewashoilretyicokusr. pet is under anesthesia. We can contact you with an estimate for treatment before proceeding with additional treatment if indicated. Please indicate below how you would like us to proceed if extractions or additional procedures are warranted: ( ) I WANT the doctor to proceed with any necessary treatment for my pet. I understand that I will be responsible for all charges incurred.
( ) I DO NOT WANT the doctor to proceed with any procedures without my consent. Please call me with an estimate before proceeding
with any additional treatment. I understand that if I am unable to be reached by phone, my pet will be recovered from anesthesia, and an
additional anesthetic procedure will be needed to correct the problem.
( ) I AUTHORIZE the doctor to proceed with any procedures up to $________________. I understand that I will not be contacted unless
the amount of the procedures exceed this amount.

I understand that there are certain risks to anesthesia that could involve serious bodily injury or death and that these risks are present in any

procedure that requires a general or intravenous anesthetic. This center takes every precaution to ensure the health and safety of your pet.

To increase the safety of any procedure involving anesthesia, we require pre-anesthetic blood work in order to determine your pet's physical

condition prior to going under anesthesia. I authorize the use of anesthesia on my pet. Initial __________

I acknowledge that changes if my pets condition or discovery of other findings during treatment may necessitate a change in or an extension

of the original treatment plan. In the event I cannot be reached, the Animal Medical Care Center has permission to proceed with medical

care that will preserve my pet's health or minimize the need for and risks of additional and costly services at a later date. Initial _________

In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to

ensure that your pet is safe and also healthy enough to undergo their procedure today. Any known risks will be discussed with you.

However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please initial your

preference:

________ Please proceed

________ No, please do not

_________ Do Not Resuscitate

with all life-saving measures.

proceed, with any treatment beyond

my pet in the event of cardiac and/or

I accept responsibility for any

non-invasive life support until I can

respiratory arrest.

costs incurred.

be reached.

Payment is due and payable upon completion of visit. Cash, Check, or approved credit card. I have read and understand the information printed above. I assume responsibility and understand any remaining balances are to be paid upon the release of my pet.
Signature: _______________________________________Date: _________________ Contact Number: _____________________ Thank you for your cooperation in helping us make your pet's stay a safe and happy one!