myvetavh.com - Dental Procedure Consent Form

Dental Procedure Consent Form
Owner’s Information
Name*

First NameLast Name
Pet’s Information
Name*
Breed*
Age*
Date of scheduled dental*

MonthDayYear
Date
Please complete the following form allowing American Veterinary Hospital to perform a dental procedure on your pet. We ask that you read the form in its entirety and acknowledge each statement. If you have questions or concerns regarding this form please contact our practice directly.
Due to the nature of the procedure, we are unable to notify owners if extractions or cavity fillings are needed at the time of the dental. Extractions are performed at an additional cost.

$35 - Easy extraction $90 - Difficult Extraction

I understand by signing this document, I acknowledge the possibility of extractions or repairs being performed at the doctor’s discretion.
As the owner, or authorized agent of the above named animal, I hereby consent and authorize American Veterinary Hospital to receive, prescribe, treat, and operate on my pet. The nature of the procedure(s) being performed has been explained to me and no guarantee has been made as to the results or cure. I understand that the practice staff and doctors will make every effort possible to minimize the risk associated with general anesthesia and the services to be performed, however all risks will be assumed by me.
- I have read, fully understand, and agree to the above.
- I understand that all fees must be paid before my pet is released from the hospital.
- I understand a written estimate of anticipated fees has been or will be provided for me upon request.
Signature of owner/agent *

Clear
Date*

MonthDayYear
Date
Contact Number*
Please enter a valid phone number.
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Dental Procedure Consent Form

Owner’s Information

Pet’s Information