Consent Form for Dental Care

You can submit our “Consent Form for Dental Care” in two ways:

1) Fill out and print our Consent Form for Dental Care here. You must bring the form printed and filled out on your next visit.

2) Fill out our form online:

Consent Form for Dental Care

"*" indicates required fields

Pet Name*

Client Name*

First Last

Phone*

Email*

I AGREE*

I, the undersigned owner or owner's agent of the pet named above, have been informed that my pet is in need of preventive or therapeutic dental care and consent to the appropriate procedures described to me by staff veterinarians at Cascade Summit Animal Hospital (CSAH). These procedures include but are not limited to the following: 1) dental prophylaxes (routine teeth cleaning and polishing), 2) extractions, 3) gingival flap surgery to close gaps left by extractions, 4) root planings, 5) dental radiographs, and/or 6) antibiotic gel implants.

CHOOSE YOUR OPTION*

OPTION 1 - I prefer to be called before any additional procedures, other than emergencies. If I cannot be reached, I authorize you to proceed with all necessary dental procedures not to exceed the amount of $1000 or (fill in $ amount - You will be able to select your custom amount later) above the estimate. I am aware that if the necessary procedure costs exceed this amount then the procedures will not be done. A second dental procedure would need to be scheduled at a later date to finish necessary procedures.

OPTION 2 - If I cannot be reached by phone, I do not authorize any unforeseen dental procedures. I am aware that this means infected teeth will be left untreated.

Option 1 Options*

Do not exceed $1000 additional

Do not exceed a custom amount

Select your custom amount:

I AGREE*

I am aware that dental procedures for animals require the use of anesthesia to: (1) maximize visualization of the gums, teeth, and oral cavity, (2) minimize movement and discomfort, and (3) provide for the safety of the pet, doctors, and hospital staff. I understand that some risks always exist with anesthesia and dental procedures, and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before these procedures are initiated. Should some unexpected life-saving emergency care be required and the attending veterinarian be unable to reach me, the staff has my permission to provide such treatment, and I agree to pay for such care. I have been informed that examinations under anesthesia often reveal abnormally loose teeth that fall out or should be extracted to prevent oral discomfort and ongoing infection of surrounding bone. I also have been informed that the loss or removal of one or more unhealthy canine teeth occasionally allows for an awkward protrusion of the tongue to one side or the other. Nevertheless, all questions and concerns I have about the recommended dental procedures have been answered to my satisfaction. I understand that an estimate of the fees for the above dental care will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered. I agree to assume financial responsibility for the remaining fees, and provide payment via cash or credit card at the time my pet is discharged. CSAH requires placement of an IV catheter to administer fluids while under anesthesia. IV fluids will aid the body in stabilizing internal organs, stabilizing blood pressure, and flushing the anesthesia out of the body more efficiently. Along with shaving the hair at the IV catheter site, we may also shave other areas including the surgical site for surgical prepping and cleansing, and also the monitor sites, so they will function properly. I agree to indemnify and hold Cascade Summit Animal Hospital harmless from and against any and all liability arising out of the performance of any of the procedures referred to above.

Please Initial*

What phone number(s) can you be reached at today:*

Are there any times you will be unavailable?*

Number to text if we can’t reach you by phone:*

Owner's Signature*

Date*

Help us fight SPAM! Please tell us what TWO plus 3 equals?*

The SUBMIT button will appear when the question is answered correctly.

This field is for validation purposes and should be left unchanged.

Monday	8:00 am - 6:00pm
Tuesday	8:00 am - 6:00pm
Wednesday	8:00 am - 6:00pm
Thursday	8:00 am - 6:00pm
Friday	8:00 am - 6:00pm
Weekend	CLOSED