Dental Consent Form Ten Ten

Owner Name *

First Name Last Name

Breed blanks*

Animal Name *

Age Sex blank*

Appt. Date Last Meal Eaten blank*

Special Diet or Dietary Restrictions

Current Medications and Time Last Administered *

Please list any known allergies or adverse reactions to medication(s) *

Dental services performed for your pet today include:
- Thorough oral cavity exam
- Probing and charting of all teeth and any abnormalities
- Scale and polish teeth
- Dental x-rays
- Formulate a treatment plan to address any problems found

*

In the event that abnormalities that require further assessment or treatment are found, I authorize GentleCare Animal Hospital to perform (please choose one):

Any and all extractions/treatments deemed necessary The extractions/treatments detailed in the provided estimate but please call if any additional extractions are needed No extractions/treatments without contacting me first

MICROCHIP: Would you like your pet to have a microchip placed while under anesthesia? ($66.40 with surgery) *

Yes No thanks Already Have One

Phone number where you can be reached between 8:30 a.m. and 3:30 p.m
Please write email address or cell number if you would also like an email or text update when your pet is awake blank*

I have read and understand the information above:*

Clear