Congratulations! Your pet is about to receive a professional dental cleaning that includes a full oral
exam, ultrasonic scaling, and polishing. This will eliminate infection in the mouth and decrease harmful
bacterial damage to your pet’s heart and kidneys.
Below are a few important conditions, please read carefully:
1. Your pet may need dental extractions to eliminate infection and resolve tooth abscess.
Please initial:
_____ I understand extractions cost $15-$25 extra for each tooth.
_____ Should there be more than ten teeth needing extraction, or the cost exceeds $150.00
for extractions, please contact me at this number: ____________________________
I also agree that should I be unavailable to contact, then extractions will be at the
discretion of the veterinarian.
2. If your pet is 6 years of age or older, it is strongly recommended that we perform preanesthetic blood work to determine that your pet can safely handle anesthesia. Blood
work costs $90.
_____ Yes, please perform blood work on my pet.
_____ No, do not perform blood work on my pet. I understand that this is
against veterinary recommendations for senior pets and my pet may
experience anesthetic complications (up to or including death).
3. We may recommend pain medication and/or antibiotics depending on the level of
infections in your pet’s mouth. This will be an additional cost.
4. I understand that all anesthetic procedures are done solely at the discretion of the
attending doctor and can be declined for any reason.
By signing below I confirm that I am the owner, responsible agent for, or authorized agent of this animal.
I understand there are risks involved with any dental procedure and that results cannot be guaranteed.
Further, in case of emergency, I consent to any necessary procedure not set forth on this form, should
that procedure be necessary and desirable in the attending veterinarian’s professional judgment. I agree
to pay in full for services performed, including those deemed necessary for medical or surgical
complications; or unforeseen circumstances. The above estimate of charges for presently planned
procedures is only an approximation and the final bill may be greater or less than this amount.
I have read and understand the above instructions. Please sign and date below:
Signed ____________________________________________________ Date ______________________