Dental Consent Form

Please fill out this form as completely and accurately as possible.

Pet Details

Pet Name(Required)
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Owner Details

Does this number accept text/SMS? *(Required)
Does this number accept text/SMS?

Patient Medical History

Any known reactions or allergies to medications or vaccinations?(Required)
Has your pet shown recent signs of illness such as vomiting, diarrhea, coughing, or sneezing?(Required)
Has your pet shown changes in appetite, drinking or exercise habits?(Required)


A veterinarian will perform a physical exam to assess your pet's overall health prior to giving any anesthetic medications. To better assess internal organ health we offer a pre-anesthetic blood panel to be performed prior to the procedure. See the attached form on blood panels for details. For patients under 7 years of age, this is optional for clients. It is important to understand that pre-anesthetic profile does not guarantee the absence of complications. It may, however greatly reduce the risk of complications and identify medical conditions that could require medical treatment in the future.
For patients under 7 years old:
In patients 7 years and older NSVC requires Pre-anesthetic blood profile and measurement of blood pressure Within 3 months of the procedure.


Once your pet is anesthetized the veterinarian will thoroughly examine your pet's teeth and gums and review dental x-rays. Your veterinarian will then call you with these results and discuss any recommendations. If any advanced dental work (Such as a tooth extraction) is recommended, an updated estimate on cost will be provided. If your veterinarian is unable to contact you or your authorized agent, we need to know your preferences.
If contact cannot be made at the phone numbers provided within 15 minutes, I prefer the following:(Required)


I would like NSVC to perform these additional treatments while my pet is in the facility:


Pain control:(Required)

The information provided on this form is true to the best of knowledge. I verify that I am the owner (or Authorized agent for the owner) of above named pet and authorize the above procedure to be performed. I authorize the use of anesthesia and other medications as deemed necessary by the veterinarian and understand the hospital personnel will be employed in the procedure(s) as directed by the veterinarian.

I have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any anesthesia episode, even in apparently healthy animals and have discussed my concerns with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I herby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian's professional judgement. I accept responsibility for any result in additional charges. I agree to be responsible for any charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital.

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This field is for validation purposes and should be left unchanged.