Dental Care and Anesthesia Consent Form

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Pet Name:*
Client Name:*
First Last
Client Email:*
Phone Number:*
Can you be reached by text if we can’ t reach you by phone?*
- Yes
- No
Blood Work Options
Your pet will be undergoing general anesthesia plus a surgical procedure today. In order to recognize any underlying abnormalities your pet may have, we recommend blood work to check the function of the internal organs. Knowing how well these organs’ function are an important part to the safety of your pet while under anesthesia.
Choose Option Below*
- Yes, I have read the above statement and would like to perform a chemistry panel to evaluate the internal organ fun ction, and a CBC to evaluate the red blood cells, white blood cells and platelet count to ensure clotting ability. This option is recommended to patients that are 6 years of age and older.
- Yes, I have read the above statement and would like to perform a chemistry panel to evaluate the internal organ function only. This is recommended for patients less than 6 years of age.
- No, I have read and understand the above statement and decline the pre surgical blood work.
Dental Care Consent:
I, the o wner or the authorized agent of the owner of the above named pet, have been informed that my pet is in need of preventative or therapeutic dental care and consent to the appropriate procedures described to me by the stage veterinarians at Goose Creek Pet Hospital ( These procedures include, but are not limited to the following: 1) dental prophylaxes (routine teeth cleaning and polishing), 2) extractions, 3) gingival flap surgery (closing of the gaps left by the extractions), 4) dental nerve root block s, 5) dental radiographs as needed, and/or 6) antibiotic gel implants.
We prefer to give you a call if any additional dental care is needed while the pet is under anesthesia, after the dental prophylaxis has been performed, and teeth have been assessed. Most dental disease is unmasked after the cleaning has been performed. Therefore, it is often noted that additional extractions or treatments may be needed after the teeth have been cleaned and assessed. Should any dental procedures be necessary and desirable in the veterinarian’s professional judgement:
Choose Option Below*
- I prefer to be called before any additional procedures, other than emergencies. If I cannot be reached, I authorize you to proceed with all necessary dental procedures not to exceed the amount of $500 or (the amount listed below) above the estimate. I am aware that if the necessary procedure costs exceed this amount, then the procedure will not be performed. A second dental would need to be scheduled at a later date to finish necessary procedures.
- If I cannot be reached by phone, I do not authorize any unforeseen dental procedures. I am aware that this means infecte d teeth will be left untreated.
Price Not to Exceed in Dental Care
Authorization for Anesthesia:
I verify I am the owner or authorized agent for the owner of the above named pet and authorize the above procedure to be performed. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian.
I am aware that dental procedures for animals require the use of anesthesia to: 1) maximize visualization of the gums, teeth and oral cavity, 2) minimize movement and discomfort, and 3) provide safety for the pet, doctors and hospital staff.
We require the placement of an IV catheter to administer fluids while under anesthesia. IV fluids will aid the body in stabilizing organs, stabilizing blood pressure and flushing the anesthesia out of the body more efficiently. Along with shaving the hair at the IV site, we may also shave other areas including the surgical site for surgical prepping and cleansing if also been performed at time of dental cleaning.
I have been advised as to the nature of this procedure to be performed and the risks involved. I also understand that there is always a risk associated with any anesthetic episode even in apparently healthy pets an d have discussed by concerns with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated, for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgement. I accept responsibility for any additional charges.
Has your pet ever had any previous reaction or issue with anesthesia?*
- Yes
- No
Name of Owner or Agent*
First Last
Signature of Owner or Agent*
Today's Date:*
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Dental Care and Anesthesia Consent Form

Blood Work Options

Dental Care Consent:

Authorization for Anesthesia:

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