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Lakeland Dental Consent Form
  • 1
    • Yes
    • Declined
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  • 2
    Pick a Date
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  • 3
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  • 4
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  • 5
    • Current on preventative
    • Product to be applied when admitted
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  • 6
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  • 7

    Nerve block: Nerve blocks are used to numb the nerves in the mouth, relieving pain. If an extraction is necessary, this will automatically be administered to your pet. ($15.00)

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  • 8
    • Yes
    • No
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  • 9
    • Yes
    • No
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  • 10
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  • 11
    • Yes
    • No
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  • 12
    • Yes
    • No
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  • 13
    • Yes
    • No
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  • 14
    • Yes
    • No
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  • 15
    • BORDETELLA
    • DHLPP
    • INFLUENZA
    • LYME
    • RABIES 1 YR / 3YR
    • FVRCP
    • FeLV
    • INTRANASAL UR
    • RABIES 1YR / 3YR
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  • 16

    I, the owner or agent for the owner, hereby consent and authorize the procedures, services, and items listed above.


    I understand during the performance of the foregoing procedure, unforeseen conditions may necessitate an extension of the procedure, or different procedure(s) than those set forth above. Therefore, I consent to the performance of such procedures as are necessary in the exercise of the veterinarian’s professional judgement. I authorize the use of appropriate anesthetics and other medications. I have been advised as to the nature of the procedure(s) and the risks involved. I realize that results cannot be guaranteed.

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  • 17
    • Yes
    • No
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  • 18
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  • 19
    Clear
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  • 20
    Pick a Date
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