Dental Anesthetic Consent Form


Please make sure that your pet has nothing to eat for 12 hours the night before the dental procedure.
The procedure will include preparation, anesthesia, monitoring, and may also include catheterization and fluid support. Your pet may also receive an antibiotic and pain management injection during the procedure. Once your pet is under anesthesia, your veterinarian will perform a complete oral exam, and carefully check your pet’s teeth and gums. During this comprehensive exam, your veterinarian may find one or more teeth that may need to be extracted for health reasons. Radiographs may be required to obtain an accurate diagnosis of the condition of your pet’s teeth and jawbone.
Based on the veterinarian’s recommendations, the following dental procedures and services may be required:

  • Routine Dental Cleaning
  • Digital X-rays of Full Mouth: (radiographs can confirm the necessity for extraction of a tooth that may be loose, damaged, or severely diseased)
  • Extractions (there are three types of extractions: Simple, Moderate and Difficult.
  • Additional anesthesia (if additional extractions are needed)

*The above procedures and services vary in cost based on the individual patient’s case. Our team would be happy to go over an estimate with you.

We highly recommend Pre-Anesthetic Blood Work to ensure that kidney and liver function is adequate to process and eliminate anesthesia. We can do the blood work on the day of the dental, or prior to the surgery. Bloodwork is an additional cost.(Required)

Should any unforeseen dental procedures be necessary in the veterinarian’s professional judgement (please choose one of the following):(Required)

I would like my pet to have the following additional procedures while sedated:

Nail Trim(Required)

Routine Ear Cleaning(Required)

Anal Gland Expression(Required)

I give my consent for Crossroads Veterinary Clinic to let my pet outside in their fenced-in courtyard unsupervised for up to 5 minutes for the purpose of elimination (urine and stool).
By siging this agreement, I am agreeing to all the above and I have the authority to authorize consent for the above-named animal to be placed under anesthesia and have the following procedure done.
If I have someone else bring in my pet for their procedure check in appointment, I give the following person permission to make decisions on my behalf.

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