Non-Anesthestic Dental Prophy Consent Form

Complete your required forms online from any device at any time before your visit.

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Owner's Name *

Email *

Pet's Name *

Sex *

Any Additional Services (not all services may be offered at this time)

I authorize Treehouse Animal Clinic's (also referred to as "TAC") veterinary staff and Animal Dental Care's (also referred to as "ADC") veterinary staff to perform the above-mentioned non-anesthetic dental prophy and/or treatment(s) listed on your pet. I Indicate with my signature my consent to the above procedure(s), that all questions have been answered to my full satisfaction and that I understand any risk associated with my pet's procedure(s). *

I consent

Signature *

Date *

Best contact number *

Vehicle you will be waiting in on the day of the procedure

TRANQUILIZATION: May not be offered at this time.

IF THE PROCEDURE CANNOT BE PERFORMED: In the event that the ADC dental technician or TAC veterinary staff finds that your pet needs to be referred to an anesthetic dental procedure for extractions, extensive dental work requiring anesthesia or that your pet will not allow the non- anesthetic procedure to be performed, I understand that the anesthetic dental procedure will not be performed today. I also understand that I will be able to schedule the referred anesthetic dental procedure when my pet is brought back out to me.

PAYMENT DUE AT TIME OF SERVICE: We accept American Express, Visa, Mastercard, Discover, Debit, Cash or Check. We do not accept Care Credit or Payment Plans.

Above policies *

I understand

Signature *

Date *

Keep your pet healthy—February Dental Month specials are here!

Non-Anesthestic Dental Prophy Consent Form

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