Dental Care Consent Form

At Governor Animal Clinic, we’re committed to providing safe, thorough, and compassionate dental care for your pet. Completing the Dental Care Consent Form ahead of your pet’s procedure allows our team to review your preferences and prepare for a smooth, well-coordinated visit.

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How to Complete the Form

Please take a few minutes to carefully fill out all required sections prior to your pet’s dental appointment. Be sure to include:

Your contact information and preferred method of communication
Approval for recommended dental treatments and procedures
Any known medical conditions or current medications
Instructions or preferences regarding additional care if needed during the procedure

This information helps our veterinarians make the best decisions for your pet’s oral health while keeping you informed every step of the way.

Complete Your Dental Care Consent Form

Completing your Dental Consent Form in advance helps us focus on what matters most—your pet’s health and comfort.

Name *

First

Last

Email *

Primary Phone *

Do you agree to receive text messages from Governor Animal Clinic? *

I agree

By checking this box, you consent to receive informational and/or promotional text messages from Governor Animal Clinic at the number provided, including messages sent by the autodialer. Consent is not a condition of purchase. Message & data rates may apply. Message frequency varies. Unsubscribe at any time by replying STOP. Reply HELP for help. Privacy Policy.

Secondary Phone

Address *

Address Line 1

City

State

Zip Code

I verify that I am the owner or authorized agent of the animal described below and consent to the anesthetic and dental procedure being performed. *

I have read, understand, and agree to the above.

Pet's Name *

Breed *

Sex *

Color

While we have tried to give you an accurate assessment of the dental procedure needed to be performed, certain factors can limit our ability to detect the extent of their dental problems during the physical exam.

These factors include:

Lack of patient cooperation to allow proper visualization, most importantly, of the back teeth.
Many periodontal problems are detected only by probing under the gum with an instrument.
Dental tartar can hide underlying cavities or fractures.
Some problems can be detected only with X-rays.

Please understand that your estimate may increase depending on the dental work needed (e.g., extractions, additional anesthesia, and medications). These fees can vary from $100 to $400 and higher to cover these costs. Every attempt will be made to contact you and inform you of any additional costs and get your authorization to proceed.

If further problems are detected while your pet is under anesthesia, how would you like them to be handled? (please choose one) *

Perform whatever procedures are needed.
Please call me at the following phone number
Do only what I have authorized. I understand that my pet may have to undergo another anesthetic episode to complete the dental treatment.

when of problems

By signing below, I agree to this procedure and the risks of the procedure have been explained to me to my satisfaction.

Signature *

Clear Signature

Today's Date *

Message

If your pet needs immediate care or you have urgent questions, please call us directly at (858) 453-6312. Online forms are not monitored for emergency situations.

Dental Care Consent Form

How to Complete the Form

Complete Your Dental Care Consent Form

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