Dental Treatment Agreement From

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Dental Treatment Agreement Form

Click here to download the dental treatment agreement form.

Owner’s Name *

First

Last

Cat’s Name *

Phone number where you can be reached today *

Your cat is scheduled for a dental procedure, which requires sedation or general anesthesia. Once we have sedated your cat, we will clean your cat’s teeth with ultrasonic scaling (the same way a dental hygienist cleans people’s teeth). After we have removed the plaque, we will examine the oral cavity again. The oral cavity can be difficult to evaluate in a cat that is not sedated, especially the backside of the teeth, and it is not possible to see what the condition of the tooth is under the plaque. Therefore, because a sedated oral examination on clean teeth is more definitive than an awake examination, more extractions may be required than initially estimated.

With this understanding, please authorize or decline the following procedures

Dental Radiographs (x-rays)

Dental radiographs can be performed prior to cleaning to evaluate each tooth and determine if there is dental disease below the gumline that would require extraction of the teeth. Dental radiographs do require general anesthesia at a higher cost than simple sedation. *

Authorize
Decline

Extractions

By declining any and all extractions, I understand the staff at Just Cats will only clean my cat’s teeth today and the doctor will let me know if extractions are recommended for a future procedure. *

Authorize
Decline

I can confirm my cat has not eaten any food after midnight last night. *

I can confirm my cat has not eaten any food after midnight last night.

I understand I am responsible for, and agree to pay the full cost at the time of pick up, including the cost of any extractions, additional medications or sedation not included in the original estimate. *

I understand I am responsible for, and agree to pay the full cost at the time of pick up, including the cost of any extractions, additional medications or sedation not included in the original estimate.

Owner’s Signature *

Date *

Name

Dental Treatment Agreement From

Dental Treatment Agreement Form

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