Dental Consent Form | Kitsilano, Vancouver Vet Clinic

Owner's Name

Email Id

Pet's Name

Pet's Age

Species

Sex

Weight

NPO

ADD

Nailtrim Microchip Anal Gland Expression Dew Claw

Blood Group

Done Accept Decline

Dental Clinic

Accept Decline

Sedation

Accept Decline

Meds to go home

Accept Decline

Radiographs $250 (Whole Mouth)

Accept Decline

Dental Extractions (If needed)

Accept Decline

Estimate

Initials

I understand that dental radiographs are mandatory as per the College of Veterinarians prior to tooth extraction. I understand that Cypress St Animal Hospital may advise me to go see dental specialist after the dental.

Please GO AHEAD with the extractions

Please CALL ME before proceeding with the extractions.

In case reasonable attempts to contact me fail, please:

PROCEED with the extractions DO NOT PROCEED with the extractions

I am the owner or agent of above pet. I have the authority to execute this consent and am over the age of 18.

I hereby authorize and direct the veterinarians at Cypress Street Animal Hospital to perform the above-described procedure(s). The nature and purpose of the procedure(s) has been explained to me, and I understand that no guarantee exists as to the result of diagnosis and treatment of the said animal. I also understand that there is no one at the hospital during the nighttime

I take full responsibility for the DECLINED tests and treatments, and I take full financial responsibility for the animal. I understand that anesthesia/surgery always carries potential risks.

I have had the fees outlined to me and agree to pay all such fees and charges at the time of discharge. I agree to pay, in full, for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. If unforeseen conditions arise, in the judgment of the attending veterinarian, call for procedures or treatments other than those now being authorized. I authorize such procedures if reasonable efforts to contact me for further consent are unsuccessful.

I understand that if an animal is not picked up within 5 days of the scheduled pick-up time, the clinic will contact SPCA and pet will be surrendered to SPCA or City Pound, which will take over the ownership of pet.

I have read and understand this consent.

Name of the Owner/Agent

Phone Number

Other Notes

Signature of owner/agent

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Dental Procedure Consent