Dental Assessment & Treatment Consent Form

Dental Assessment & Treatment Consent Form

Your Name:

Contact Info

Telephone numbers where you can be reached today during the dental procedure:

Phone 1

Phone 2

Phone 3

Pet Name:

Phone Type

Phone Type

Phone Type

Alternate Contact

Emergency # of someone authorized to make decisions for you if you cannot be reached:

Alternate Name:

Alternate Phone Number:

It is very important that the doctor be able to reach you during the dental procedure to discuss the dental assessment and estimate for treatment when needed. We will always call you first at all numbers listed above. If you or your agent cannot be reached, please indicate your choice by signing one choice below:

Consent Option 1
 Treat my pet as needed. Do any and all diagnostic tests, treatments, extractions and oral surgeries necessary for the well-being of my pet. I accept full financial responsibility for all charges incurred by my pet.

Consent Option 2
 Do not perform any additional diagnostic tests, treatments, extractions or oral surgeries, besides the ones on my original estimate, without contacting me first.

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51 Vickers RdChapel Hill, North Carolina 27517Get Directions(919) 942-6330


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