Name: Mountainside Animal Hospital
Address: 22035 SE Wax Rd, Suite 3, Maple Valley, WA, 98038, US
Telephone: 425.584.7749
Price range: $$

Consent for Dentistry

Patient Name*
Age*
Sex*
Breed
Species
Consent*
I agree to this statement
I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. My signature below certifies that I am over eighteen years of age.

I have been informed that there are certain risks and complications associated with sedation, anesthesia, and/or any operation/procedure and that the risks/complications have been explained to me. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before the procedure is initiated.

I authorize the use of appropriate anesthesia and pain relief medication as needed before, during or after the procedure. I have been informed that there are risks associated with the use of any medication.

The nature of these operations or procedures has been explained to me and I understand what will be done. I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. I have been encouraged and given the opportunity to discuss any questions I may have regarding my pet's medical care and my questions have been answered to my satisfaction. I accept that my financial obligations remain regardless of the outcome.

I have read and understand this authorization and hereby accept and agree to the terms of the consent for treatment.
Best phone number to reach you TODAY*
Dental Extraction Consent*
- I agree to additional extractions as deemed necessary by the Veterinarian
- I elect NO additional extractions beyond what has been estimated in my treatment plan.
I understand that the treatment plan that I have been given is only an estimate of cost and that during the performance of all dental procedures, unforeseen circumstances may require additional extractions of teeth that cannot be predicted beforehand. Due to not wanting to prolong the patient being under anesthesia, we will ONLY attempt to contact you ONE TIME if additional extractions are needed. By consenting below, you are consenting to authorize the performance of such procedures as being necessary for the exercise of the veterinarian's professional judgment without notification. If we are unable to reach you after one phone call attempt, then we will proceed as deemed necessary by the Veterinarian. By consenting to this service, you are also acknowledging that certain fees will apply.
CPR Consent*
- I agree to CPR being performed in case of cardiac or respiratory arrest.
- I elect a “Do Not Resuscitate” status in case of cardiac or respiratory arrest.
In the event that the patient should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of the patient's status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion. Please initial your choice below.
Optional Add-On Services
- Select All
- Nail Trim (Complimentary)
- Microchip w/Temperature Reading Feature *Fees Apply*
- Laser Therapy *Fees Apply*
Please select any optional add-on services that you would like performed today.

Consent for Dentistry

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