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Dental Consent Form

Please complete the form below before your appointment. if you have questions, please call us at 785-267-1012.

Your pet is scheduled for a dental procedure at Burlingame Road Animal Hospital. We utilize the safest anesthetics and maintain continuous monitoring throughout the process. It's important to note that all anesthetics and surgical procedures carry inherent risks, irrespective of the pet's age or health condition

I herby authorize the performance of the following dental procedure: *

Owner *

First

Last

Email *

Phone number you can be reached at today:

Pet's Name *

Breed *

All admitted animals must have up-to-date vaccinations and be free of external parasites. Any instances of fleas or ticks will be treated at the owner’s expense.

Adhering to the gold standard of care, dental radiographs are routinely taken during the dental procedure to assess potential tooth extractions. In the event we are unable to reach you to discuss a treatment plan post radiographs, we offer the following options for your consideration.

Please check your choice below:

Goes with above code block *

Please do anything that you deem necessary for the dental health of my pet.
Please do an additional $________ worth of extractions in the event you cannot reach me (enter below)
Do not proceed with any procedures without my explicit permission. I understand that this may require waking and extubating the patient for timely decision-making.

Pre-operative blood testing to reduce risk: To reduce the risk of anesthesia, a simple blood test can be performed on the day of surgery. This test provides information regarding the function of your pet’s internal organs, such as the liver and kidneys. The test can alert us to some of the more common problems so that extra precautions can be taken. The fee for the testing is $166.42 for dogs and $151.24 for cats. Please initial your choice below: *

Yes, I want my pet to have a pre-surgical blood profile.
No, I do not want my pet to have a pre-surgical blood profile.

Your signature below confirms that:

✓ You have read this form

✓ You understand that there are risks associated with anesthesia and surgery, and

✓ Payment for all treatments is due and payable when you pick up your pet.

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Dental Consent Form

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