Dentistry Addendum Consent Form

This form is an addendum to the Pre-anesthetic Consent Form. The Pre-Anesthetic Consent form must be completed first.

Owners First and Last Names*
First Last
Pet's Name*
Do you authorize diseased teeth to be extracted, if indicated, without notification before the procedure?*
- ACCEPT
- DECLINE
Teeth will only be extracted if it is in the best interest of your pet. Please be aware that tooth extractions are NOT included in the price of the dental cleaning. This cost is additional.
Do you request to be notified before any extractions?*
- ACCEPT
- DECLINE
If yes, what phone number will you be available at? (Please note, the Dr. will call and wait 10 min only for a response, if you are not available, the tooth will be left in place)
Accuracy and Agreement/Consent*
I AGREE AND CONSENT
Information provided is accurate to the best of my knowledge and I understand there are additional charges for services selected above. Where a service has been declined, I understand those services will not be performed.
Date of agreement and consent*
MM slash DD slash YYYY
Signature*
Sign with finger if mobile phone or tablet, drag mouse if PC or Mac.
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

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