Consent for Dental Treatment

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Consent for Dental Treatment

So that we can prepare for your cat’s procedure, please complete and submit this form at least 48 hours before your scheduled appointment.

Printable Version

Name *

First

Last

Email *

Phone *

Cat's Name *

Procedure(s) Being Performed: *

Description of Services

Your cat will be undergoing general anesthesia for a dental procedure today. During general anesthesia, your cat is completely unaware of his/her surroundings and is not responsive to external stimuli. For your cat’s comfort and safety, he/she will receive oxygen and anesthetic gas through a breathing tube and receive fluids and medications through an intravenous (IV) catheter.

Once your cat is anesthetized, we will conduct a thorough oral examination, take x-rays of all teeth, and perform a professional dental cleaning and polishing.

After the oral exam and review of the x-rays, the doctor may determine that your cat needs additional treatment beyond what you’ve authorized on the Treatment Plan. In these cases, a separate treatment plan and estimate will be made. Depending on the severity of disease present, the doctor may recommend splitting your cat’s treatment into two stages. The first stage would be completed today and the second stage would be scheduled for a later date.

I would like the doctor and/or his agents to do the following (choose ONE): *

Attempt to contact me at the phone number listed above. If you cannot reach me, please do whatever the doctor determines to be medically necessary. I understand I will be responsible for additional charges.
I do not authorize any additional procedures beyond what is stated in the Treatment Plan. I understand my cat may require additional anesthetic procedure(s) at a late date to address diseased teeth.

Please read the following statements, then sign below.

I have been advised of the nature of the services and procedures included in the Treatment Plan, as well as the risks involved. While I expect all procedures to be performed to the best of the staff’s abilities, I realize that medical results cannot be guaranteed. *

I have read and agree

I understand that, although uncommon, complications can occur with any dental procedure, including but not limited to the possibility of infection, bleeding, blood clots, swelling, and bruising. Additional complications for this specific procedure have been discussed with me. *

I have read and understand

I understand that abiding by the post-operative instructions is crucial for a proper recovery and to help avoid postoperative complications. *

I have read and understand

I have reviewed and approved the Treatment Plan presented to me. I understand that a deposit of 100% of the lower end of the estimate is due when my cat is admitted to the hospital, and that the remainder of the invoice is due in full at discharge. I understand that the estimate may not be a complete representation of my final bill if additional procedures are performed. *

I have read and agree

I understand that during anesthesia, dental treatment, or recovery, unforeseen conditions may be revealed that necessitate an extension of the procedure, or even procedures different than those set forth in the Treatment Plan. *

I have read and understand

I acknowledge that I have read this form, that I understand the risks, alternatives, and expected results of the dental procedure, and that I had ample time to ask questions and to consider my decisions. *

I have read and agree

Signature *

Date *