Please answer the following questions as they relate to what anesthetics are given to your pet:

Has your pet ever had a seizure?

Has your pet ever had trouble with anesthesia?

All Hospitalized patients must have proof of a current rabies vaccine.

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff has my permission to provide such treatment and I agree to pay for such services (Costs can build quickly.).

I am the owner or agent for the above pet and have the authority to execute this consent. I hereby consent and authorize Douglas Blvd Veterinary Clinic to perform a Dental cleaning procedure. I understand that during the procedure, unforeseen conditions may be revealed that necessitate an extension of the forgoing procedure. Therefore, I hereby consent to and authorize the performance of such procedures and or surgery as are necessary and desirable in the exercise of the veterinarian's professional judgment. I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed by the veterinarian.

Signature: (sign freehand)


Please leave a number(s) where we can reach you. Sometimes we will find that once we perform a complete dental exam, other issues may arise, such as extractions. WE MAY NEED TO REACH YOU DURING YOUR PET'S ANESTHETIC PROCEDURE, WHERE TIME IS A CONCERN. If we CANNOT reach you, we will proceed with whatever is the best medical interest of your pet and you will be financially responsible. Initial

Phone Number:

Dental Package Price Ranges

All dental packages include the following:

  • Inpatient Exam
  • General Anesthesia
  • Registered Technician Anesthetic Monitoring
  • Dental Prophylaxis
  • Teeth Polishing
  • Intravenous Catheter
  • Fluoride Treatment
  • Fluids during anesthesia
  • Full mouth radiographs
  • Bair Hugger Warming Device
  • Day Hospitalization
  • Toe Nail Trim
  • Ear Check
  • Anal Gland Expression

I understand the highlighted package is the estimated costs for my pets procedures

Signature: (sign freehand)


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