Dental Procedure Consent Form
Anesthetic oral exam, cleaning & extraction authorization
01
Client & patient
02
Planned procedure
03
If teeth need to be extracted
Most dental disease is below the gumline and can only be fully assessed with radiographs under anesthesia, so the need for extractions often isn’t known in advance.
04
Risks
I understand that general anesthesia carries risks, including rare serious complications and, in rare cases, death. Dental treatment can cause bleeding, swelling, and soreness. Uncommon complications include an opening between the mouth and nose after upper canine extraction, and jaw fracture in small dogs with severe bone loss. These risks will be explained further for my pet if they apply.
05
Decisions
Pre-anesthetic bloodwork
IV catheter & fluids
Resuscitation status
06
After the procedure
What to expect at home after extractionsSome drooling, a little blood-tinged saliva, and reduced appetite for a day or two are common. Soft food and pain medication as directed help. Call us for heavy bleeding, facial swelling, or if your pet won’t eat after 24 hours.
07
Acknowledgments
Please initial each statement
- The procedure, its risks, and the alternatives were explained to me, and my questions were answered.
- I understand the final cost depends on what is found and the extraction option I chose above.
- I am the owner of this animal or am authorized to make medical decisions for it, and I agree to pay for services provided.
Owner / authorized agent signature
Staff witness signature
08
At discharge
Completed by the dental team| Tooth | Finding | Treatment |
|---|---|---|
Home care