Free · Unbranded · Consent & legal
A consent form for dental cleanings under anesthesia. Its key feature is the extraction decision: the client chooses up front whether to call first, approve extractions up to a set amount, or decline, so nobody is chasing a phone call with the patient under anesthesia.
Unbranded: no logo or linksNo account neededPrint at 100% on US LetterUpdated
What’s on the form
Contact details, the patient, date, veterinarian, and the low and high estimate the client received.
Oral exam and charting under anesthesia, full-mouth radiographs, scaling and polishing, and optional sealant or local blocks.
Extract what the veterinarian finds diseased, call first, approve up to a set amount, or no extractions, plus a reachable phone number.
Anesthetic risks plus dental-specific ones: bleeding, swelling, oronasal fistula after upper canine extraction, and jaw fracture in small dogs with severe bone loss.
Pre-anesthetic bloodwork, IV fluids, resuscitation status, and initialed acknowledgments.
What to expect at home after extractions, then client and staff signatures.
A findings and extractions summary, the home-care plan, and the recheck date, so the same sheet goes home with the client.
Fill in online
Every line on the form is editable right here. When you’re done, print it or choose “Save as PDF” in the print dialog. Everything stays in your browser.
Click any line to type, or add your logo. Nothing is uploaded or saved.
Using it well
Most dental disease is below the gumline and only shows on radiographs under anesthesia. Clients accept a range more easily when they understand why.
An approved amount for extractions without a call is the single biggest time-saver in a dental day.
Showing the client the dental chart and radiographs at discharge turns an unexpected bill into an understood one.
Printing, editing, and what the form does and doesn’t cover.
A dental procedure often turns into treatment decisions (extractions, oral surgery) that can only be made once the patient is under anesthesia and radiographs are taken. The form records how the client wants those decisions handled.
The client authorizes additional treatment up to that amount without being called. Anything above it, the team calls first. It keeps anesthesia time down when the owner can’t be reached.
They describe recognised complications (bleeding, swelling, oronasal fistula after upper canine extraction, and jaw fracture in small dogs with severe bone loss) in general terms. Your veterinarian should explain the risks specific to each patient.
Yes. Fill in the estimate fields online before printing, or attach your itemised estimate. The estimate template on VetStack works well alongside this form.
2 pages, US Letter, landscape
A landscape dental chart with every tooth drawn and numbered in the modified Triadan system: a full canine page and a full feline page. Each tooth gets mobility, probing depth, and findings boxes, with staging, procedures, and home care below.
2 pages, US Letter, portrait
An admission consent form for anesthesia and surgery. It captures the procedure and estimate, fasting and medications, the client’s decisions on bloodwork, fluids and resuscitation, and what to do if something unexpected is found.
1 page, US Letter, portrait
A one-page itemized estimate with low and high columns, totals, deposit, and an expiry date. Clients choose accept, decline, or a partial plan and sign, so the decision and the numbers are on the record together.
A starting point, not legal or clinical advice. VetStack’s forms are general templates. Requirements for medical records, consent, and controlled substances vary by state and practice, so review the wording with your practice’s attorney and check your state veterinary board’s rules before adopting a form as standard.