Dental Anesthesia / Sedation Release Form

Our Dental Anesthesia/Sedation Release Form provides important information about your pet’s upcoming dental procedure and allows us to obtain your consent for anesthesia services. Completing this form helps our team deliver safe, effective dental care while maintaining the highest standards of patient monitoring and comfort.

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Dental Anesthesia / Sedation Release Form

Please complete this form prior to your pet’s dental procedure:

Patient Name *

Date of Procedure *

Owner Name *

First

Last

Owner Phone Number *

Patient’s Weight *

Please indicate weight in lbs.

Owner Address *

Address Line 1

Address Line 2

City

State

Zip Code

Has your pet fasted today? *

When was the last time he/she ate or drank? *

Please list any current prescription medications, over-the-counter medications, and/or supplements (including vitamins). Include the strength, route of administration, and time administered. *

In your own words, please describe the location and procedure being performed today: *

Pre-Anesthetic Blood Work: To provide the best possible care for your pet, we recommend pre-anesthetic blood work to check the functions of the liver and kidneys. These are the two organs that process the anesthesia. If you decline pre-anesthetic blood work, your signature on this document is in agreement that you will NOT hold All Vet Care, its doctors, or staff responsible in any way for the loss of your pet, assuming all other reasonable precautions have been taken. *

Dental X-rays: To provide the best possible care for your pet during dental procedures, we recommend dental X-rays. These images allow us to thoroughly evaluate the health of the teeth and gums below the surface, identifying any underlying issues such as root infections, fractures, or bone loss that are not visible during a routine examination. If extractions are necessary, dental X-rays are essential to ensure that no tooth fragments or roots are left behind, as retained roots can lead to pain, infection, and further complications. By opting out of this procedure, you agree that All Vet Care, its doctors, or staff cannot be held responsible for undetected dental conditions or complications, assuming all other reasonable precautions have been taken. *

Microchip Implantation: Microchip implantation is always recommended to give you the best chance of being reunited with your pet if any unfortunate event takes place. This microchip will be the first thing shelters scan for whenever they find any lost pets. (copy) *

I authorize using appropriate anesthetics and other medications in my pet’s best interest. I have been informed about the nature of the procedure, including the risks involved. In the event that more extractions are required than originally estimated, we will attempt to contact you at each phone number on file or otherwise available. Please note that the doctor reserves the right to remove any teeth determined to be medically necessary. I fully understand the risks involved with sedation, anesthesia, and/or the surgery of my pet and do NOT hold All Vet Care, its doctors, or staff responsible in any way for the loss of your pet, assuming all other reasonable precautions have been taken. I understand that during the course of the procedure(s), unforeseen conditions may arise that may necessitate the performance of additional procedures. Furthermore, I understand that payment is due at the time services are rendered, and I know I will be given an estimate upon request. I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to provide this consent. My signature below certifies that I am over eighteen years of age.

Signature *

Clear Signature

Today's Date *

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