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Dental Exam & Treatment Consent Form

Name: Puyallup Valley Veterinary Clinic
Address: 2208 E Main Ave, Puyallup, WA, 98372, United States
Telephone: 253-845-8122
Price range: $

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Dental Exam & Treatment Consent Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 253-845-8122 for a faster response.

Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Patient Name *

Species *

Breed *

Age *

Sex *

Male
Female
Neutered Male
Spayed Female

A DENTAL EXAM can help us understand your pet’s oral health and aspects of your pet’s overall health. However, a thorough exam of your pet’s mouth, teeth and gums cannot be accomplished without the use of anesthesia. In order to minimize the time that your pet is under anesthesia, it is important that we have clear instructions from you in advance with respect to how you would like us to treat any condition that we may discover during the anesthetized dental exam.

PLEASE CHOOSE ONE: *

Proceed with ANY procedure the veterinarian deems necessary to treat ANY condition identified during the dental exam, including ANY treatment to minimize any pain my pet may experience in the future from on-going dental disease. This includes dental extractions if needed which may exceed the initial estimate.
Proceed with ANY procedure you deem necessary to treat any condition you identify during the dental exam, BUT DO NOT EXCEED $_____________ without contacting me first.
DO NOT proceed with ANY procedure without contacting me first. *If we are unable to contact you, extractions and any other treatment/procedure will NOT be done*

BLOOD WORK: It is our job to ensure that your pet can properly process and eliminate the anesthetic he/she is given today. Before we perform any procedure requiring anesthesia, we require pre-operative blood work on your pet. With testing, we are able to confirm that your pet's organs are functioning properly and could potentially reveal any hidden health conditions that could put your pet at risk.

PLEASE CHOOSE ONE: *

YES, my pet has already had blood work done on ___________________ date.
NO, my blood work needs to be done, in hospital, prior to anesthesia today.

I am the owner (or authorized agent of the owner) of the animal described above, and have the authority to execute this consent. I understand that some risk always exists with anesthesia, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian and understand that it may be necessary to provide additional medical or surgical treatment to my pet in the event of unforeseen circumstances. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. Subject to my directions above, I hereby authorize the use of anesthetics and other medications, as well as any such additional treatment, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read, and fully understand, this consent. The fees associated with these services have been explained to me with an estimate, and I agree to pay such fees in full at the time my pet is released from the hospital.

Understand that if your pet is found to have fleas we have the right to treat at your expense. Initial Here. *

Signature *

Date *

PHONE (best number to be reached today): *

SECONDARY # (if we cannot reach you on above #) *

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Dental Exam & Treatment Consent Form

Dental Exam & Treatment Consent Form

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