Owner's Name *

First

Last

Phone *

Email *

Pet's Name *

Species *

Breed *

Age *

Is your pet currently taking any medication? *

Yes
No

If yes, please specify: *

Has your pet ever had an adverse reaction to a medication? *

Yes
No

If yes, please explain:

Is your pet on heartworm prevention? *

Yes
No

Is your pet on flea and tick prevention? *

Yes
No

Reason for visit (check all that apply)

If other, please specify: *

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 dental exam. *

Proceed with any procedure you deem necessary to treat any condition you identify during the dental exam, including any treatment to minimize any pain my pet may experience in the future from ongoing dental disease.
Proceed with any procedure you deem necessary to treat any condition you identify during the dental exam, but do not exceed my written estimate without contacting me first.
Do not proceed with any procedure without contacting me first.
Other

If Other, please explain: *

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. *

I have read and understand.

I have received guidance regarding the nature of the proposed procedure(s) and/or operation(s), including the associated risks. I acknowledge my responsibility to cover all costs related to these procedures. *

I have read and understand.

Signature *

Clear Signature

Today's Date *

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We proudly serve the pets of Oak View, California and beyond.