Procedure Consent Form

"*" indicates required fields

Owner Contact Information

Pet Owner Name*
Please enter a phone number you can be easily reached at on the day of the procedure.
Pet Owner Address*

Pet Information Details

Procedure Details

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Pet Owner Release

I hereby certify that I have read and fully understand this authorization for treatment. I am the owner or agent for the above-described animal, am at least 18 years of age and have the authority to execute this consent. If unforeseen conditions arise which, in the judgement of the attending veterinarian, call for procedures or treatments other than those now being authorized, I authorize such procedures if reasonable efforts to contact me for further consent are unsuccessful. I understand that I am responsible for the additional charges should additional procedures be required. I understand some risks always exist with medication, procedures, anesthesia and/or surgery, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) is initiated. My virtual signature on this consent form indicates that any questions have been answered to my satisfaction. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures.
MM slash DD slash YYYY
Pet Owner Signature*

Social Media Release

Pet Owner Signature


Pet Owner Signature*

Health Concerns

Pet Owner Signature*

Dental Procedures **This section is only to be signed if your pet is coming in for a dental procedure. Please disregard this section if not applicable**

Many oral health issues can not be detected until a thorough dental exam is performed under anesthetic. I understand that there may be additional extractions or dental procedures required that were not initially noted during the clinical exam. Complications of dentistry are rare but can include hemorrhage, nerve injury, destabilization or fracture of the jaw, retained root material, loss of teeth adjacent to the extraction and infection.
If additional extractions are required, I would like to be called before they are performed.*
Pet Owner Signature*

Pediatric Anesthesia Procedures **This section is only to be signed if your pet is coming in for a pediatric anesthetic procedure (i.e., a spay or neuter). Please disregard this section if not applicable**

In some cases, the baby teeth do not fall out and both the adult and baby tooth are contained in one socket. These are called persistent deciduous teeth and can pose a problem for long-term dental health if they are not addressed.
In the event that persistent deciduous teeth are noted, I consent to extraction of the retained baby tooth while under general anesthesia.*
Pet Owner Signature*


The day before the procedure, one of our technicians will be reaching out to review the estimate, confirm a drop-off time, and answer any questions you may have. This phone call typically takes place in the afternoon.

If you have any questions or concerns you would like addressed prior to this phone call, please do not hesitate to reach out via phone or email. We look forward to seeing you and your pet soon!

Sincerely, The Veterinarians & Staff of Ilderton Pet Hospital