Please Note: We will be closing early at noon on Tuesday, December 24th and will be closed on Wednesday, December 25th in observance of Christmas!

Online forms

Dental Consent Form

Save time during your next appointment! Complete your required forms online from any device at any time before your visit.

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Dental Consent Form

Thank you for entrusting Cypress Veterinary Clinic for your pet’s care!
Please fill out our dental consent form in its entirety.

Name *

First

Last

Email *

Pet's Name *

Emergency Phone Number *

Secondary Emergency Phone Number

A dental exam can help us understand your pet’s oral health and aspects of your pet’s overall health. However, a thorough exam of your pet’s mouth, teeth and gums cannot be accomplished without the use of anesthesia. In order to minimize the time that your pet is under anesthesia, it is important that we have clear instructions from you in advance with respect to how you would like us to treat any condition that we may discover during the dental exam.

Please Choose One *

Proceed with any procedure you deem necessary to treat any condition you identify during the dental exam, including any treatment to minimize any pain my pet may experience in the future from on-going dental disease.
Proceed with any procedure you deem necessary to treat any condition you identify during the dental exam, but do not exceed my written estimate without contacting me first.
Do not proceed with any procedure without contacting me first.
Other

If Other, please explain: *

When was the pet's last meal? *

Is your pet on any medications? *

If yes, what medications and when were they last given? *

Is there anything else needed while pet is under anesthesia (check all that apply)? *

Courtesy Nail Trim
Heartworm test
FeLV/FIV testing
Check ears
Clean ears
Express anal glands
Fecal testing
Update vaccines if possible (Dr. Discretion)
Microchip
Pre-anesthetic Blood work
Biopsy
Refill of preventions
Other

Please specify other service *

CPR in animals, like in humans, is a life-saving procedure that uses medications, artificial breathing and chest compressions. This is to help revive the pet when they stop breathing on their own and/or their heart stops beating.

CPR consent *

I DO want CPR performed on my pet if my pet goes into respiratory or cardiac arrest.
I DO NOT want CPR performed on my pet if my pet goes into respiratory or cardiac arrest.

I understand that there may be restrictions to my pet’s activity and agree to follow the recommended post-operative instructions after this procedure

I have read and understand

I understand that CVC recommends current blood work (4 weeks or less) for any procedure requiring anesthesia regardless of age *

I have read and understand

I am the owner (or authorized agent of the owner) of the animal described above, and have the authority to execute this consent. I understand that some risk always exists with anesthesia, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian and understand that it may be necessary to provide additional medical or surgical treatment to my pet in the event of unforeseen circumstances. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. Subject to my directions above, I hereby authorize the use of anesthetics and other medications, as well as any such additional treatment, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read, and fully understand, this consent. *

I have read and understand

The fees associated with these services have been explained to me, and I agree to pay such fees in full at the time my pet is released from the hospital. *

I have read and agree

Today's Date *

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Address

753 West Cypress Street
Kennett Square, PA 19348

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Contact

E: [email protected]
P: 1-484-734-0686

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Hours

Mon, Tues, Wed, Fri: 8 am – 6 pm
Thurs: 8 am – 5 pm
Sat & Sun: Closed

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