Belmont Animal Hospital - DENTAL CONSENT FORM

1

Pet Name

2

Owner

First Name

Last Name

3

Contact Details

Contact Number

Secondary Contact Number

4

Email* This field is required.

example@example.com

5

Current Medications

6

Pet’s Previous Health Concerns

7

Additional Requests or Procedures

8

If teeth extractions are indicated

I authorize all necessary tooth extractions.

I would like to be called prior to extractions. If I am unavailable, I understand the decision for extractions will be at the doctor’s discretion.

9

While your pet is under anesthesia, we can implant a Microchip. These have helped reunite thousands of lost pets. The microchips are pain free and do not cause any problems as your pet ages. We strongly recommend having all companion animals chipped for identification purposes. Would you like us to microchip your pet today?

Yes

No

Already Microchipped

10

Date

11

All surgical procedures require general anesthesia. Anesthesia carries certain risks and potential complications. To minimize these risks, we require pre anesthetic blood work and IV catheters for all procedures involving general anesthesia.I have read and understand the above information. I give permission for the procedure and agree to full payment at the completion of services.

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