Consent for Dental Treatment and Assessment

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I have read and understand this authorization and hereby accept and agree to the terms of the
consent for treatment.

I have been informed that there are certain risks and potential complications associated with
sedation, anesthesia and/or any operation/procedure/treatment/medication that may result in
injury, harm or even death from both known and unknown causes. These risks and potential
complications have been explained to me to my satisfaction. I further understand that during the
course of the operation(s) or procedure(s), unforeseen conditions may arise that may require the
performance of additional urgent care services deemed necessary by the attending veterinarian. I
am encouraged to discuss any concerns I have about these risks with the attending veterinarian
before the procedure is initiated.

I authorize the use of appropriate anesthesia/sedation, hospitalization, diagnostic testing, patient
monitoring, treatments and medications as needed before, during or after the procedure.

I understand that a treatment plan providing the details and costs for the anticipated veterinary
services will be provided to me, and that I am encouraged to discuss all fees attendant to such
care before services are rendered and during my pet’s ongoing medical treatment.

I further agree, that either I, or an authorized agent of mine will promptly pick-up and pay for all
accrued charges when I have been notified that my pet is ready to be released from the hospital.
I agree that if I fail to comply with this policy within five days of oral or written notification of
the readiness to be released, that Companion Skokie may handle this abandonment in the best
interests of the pet and/or the hospital in accordance with the local laws and I will still be
responsible for all fees incurred.

The nature of these operation(s) and/or procedure(s) has been explained to me to my satisfaction
and I understand what will be done. I am aware that the practice of veterinary medicine is not an
exact science and I understand that no warranty or guarantee has been either expressed or
implied as to a cure or a specific result. I have been encouraged and given the opportunity to
discuss any questions I may have regarding my pet’s medical care and my questions have been
answered to my satisfaction. I accept that my financial obligations remain regardless of the

I have read and understand this authorization and hereby accept and agree to the terms of the
consent for treatment.

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Emergency Contacts

Unanticipated Dental Needs Plan

During the dental procedure detailed information about your pet’s oral health is made available from the in-depth oral exam and/or intra-oral x-rays that are only possible while your pet is under anesthesia. Due to this fact, during the procedure it may be determined that your pet’s dental disease and/or treatment needs may be more severe than originally anticipated. In the event that your pet’s dental treatment needs are materially different than originally planned, the hospital will make every reasonable effort to contact you at the emergency contact numbers provided during the procedure. However due to the need to limit procedure time, cost and anesthesia risk, if I am unable to be reached promptly, then the hospital staff must decide whether we perform the necessary oral surgery/additional treatments today while your pet is still under anesthesia if the attending veterinarian feels this is appropriate. Staging of the dental disease/oral surgery into multiple procedures may be required to best manage your pet’s comfort and anesthesia risk. Once your pet has recovered from anesthesia they will not be able to be put back under anesthesia in the same day.*

Emergency Care Plan

In the event that my pet requires emergency care during the stay, I understand that the hospital
will make every reasonable effort to contact you at the emergency contact numbers provided.
However, if I am unable to be reached prior to the time when the performance of the necessary
care is deemed to be required by the attending veterinarian, the hospital’s staff has my
permission to provide any necessary medical care for my pet.


In the event that your pet should experience cardiac or respiratory arrest while being
hospitalized, do you give consent for resuscitative efforts to be initiated until you can be
contacted further and notified of pet status?

By consenting to this service, you are also acknowledging that certain fees will apply. If you are
not able to be contacted immediately, resuscitation efforts will be continued to be performed at
the doctor’s discretion. Please select and initial your choice below.

CPR Choice*

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