Pet's Name
Owner’s Name*
Email
Please read and initial ALL of the following:
Initial Here
I understand that the practice of veterinary dentistry is not an exact science and that guarantees as to outcome are not possible. The dental procedure and treatment options have been explained to my satisfaction and I give my informed consent to carry out the dental procedure and treatments.
Initial Here
I understand that the ultimate success of the proposed dental treatment may depend on adequate home-care and follow-up, and I acknowledge my responsibility in this regard. This is particularly so with the management of periodontal disease.
Initial Here
I understand that, although rare, complications can occur while performing a dental procedure and treatments to my pet. I acknowledge and understand that complications arising from my pet’s dental procedure and treatments could include, but are not limited to, infections, broken jaw, and allergic reactions to medications. All precautions will be taken to minimize such complications.
Initial Here
I understand that cleaning my pet’s teeth is a surgical dental procedure and does require general anesthesia, and could potentially involve risks and complications for my pet. I acknowledge and understand that the risks and complications arising from general anesthesia could include, but are not limited to, cardiac arrest, and death. All precautions will be taken to minimize such risks and complications.
Initial Here
In the unlikely event of an anesthetic complication, I authorize CKVC to carry out such procedures and treatments deemed appropriate. I realize that I will be responsible for charges associated with such procedures and treatments.
Initial Here
I give CKVC permission to photograph my pet for the purpose of documenting the treatment and I understand that the photographs may be used for educational purposes. Confidentiality is assured.
Initial Here
I certify, as instructed to me by the treating veterinarian or CKVC staff, that my pet has not had anything to eat after 8pm the day before surgery (minimum 12 hours prior to surgery/drop off at the clinic). Or, if not (if I am unsure whether my pet ate anything on the day of surgery), I accept all responsibility for assuming the increased potential for risk of complications that may arise from my pet’s aspiration (inhalation of regurgitated stomach contents) while under sedation, anesthesia, or recovery from anesthesia.
Initial Here
I understand that pre-anesthetic bloodwork is required and additional tests may be recommended for my pet. If pre-anesthetic bloodwork/tests have not already been completed, I understand they will be performed prior to anesthetizing my pet on the day or admission for the dental procedure and treatments.
Initial Here
The treating veterinarian or CKVC staff has informed me of the risks and benefits associated with the dental procedure and treatments to be performed on my pet. I understand that there are known and unknown risks associated with a dental procedure and treatments. Hereby, I expressly agree to release Cherry Knolls Veterinary Clinic, LLC, and its agents and its representatives, from liability for any and all damages to my pet and agree to hold CKVC, LLC, its agents and representatives harmless from any all liability (except in the case of gross negligence) associated with the dental procedure and treatments being performed on my pet.
Initial Here
I agree to pick up my pet from CKVC at the time discussed with the treating veterinarian or CKVC staff unless prior arrangements have been made (such as boarding). I understand that failure to retrieve my pet may be considered abandonment. If my pet is abandoned, I understand that my obligation to CKVC, for full complete payment of all medical care, boarding, and related fees shall remain my responsibility, regardless of the outcome of the dental procedure and treatments.
Initial Here
I understand that payment in full is due upon completion of the dental procedure and treatments. No exceptions can be made unless previously discussed with Meghan Shannon, DVM (owner of CKVC, LLC). In the event that my pet’s health insurance does not provide payment to the clinic, I agree to assume full responsibility for payment
Initial Here
I understand that the estimate given is only an estimate and is based on a pre-anesthetic examination. I understand that certain problems related to my pet’s teeth and gums cannot be identified until my pet has been anesthetized and a more thorough oral examination of my pet’s mouth has been performed. New information which comes to light during the more detailed oral examination could include but are not limited to, resorptive lesions, cavities, broken/loose teeth, abscessed teeth, and this may make the estimate invalid. In the event that additional procedures are required that are not outlined on the original estimate given:
Please read and initial ONE of the following:
Initial Here
I authorize testing and treatments as outlined on the estimate given and place no limit on additional charges/services carried out at the veterinarian’s discretion.
Initial Here
I authorize testing and treatments as outlined on the estimate given and approve charges up to an additional $
Price
Initial Here
Please call me with a revised estimate before performing any additional testing and treatments not outlined on the estimate given. If I cannot be reached, I authorize additional testing and treatments deemed appropriate by the veterinarian.
Initial Here
Please call me with a revised estimate before performing any additional testing and treatments not outlined on the estimate given. I understand that if I cannot be reached, my pet will receive NO additional testing and treatments other than those outlined on the original estimate.
Please read and sign the following:
Initial Here
(patient), I hereby give my consent to Cherry Knolls Veterinary Clinic, LLC to perform the above said dental procedure and treatments.
Date
Please leave the name and at least two telephone numbers of the primary person that can ban be reached today regarding the care of your pet.
Primary Contact Name
Primary Phone Number
Secondary Contact Name
Secondary Phone Number
Submit ↗
