Dental COHAT Procedure Authorization Form

Secondary Emergency Contact:

PURPOSE OF THIS FORM

This document provides informed consent in accordance with the Illinois Veterinary Medicine and Surgery Practice Act (225 ILCS 115) and generally accepted veterinary medical standards. It explains recommended treatment, potential risks, alternatives, and financial responsibility. It is intended to help you understand the care recommended for your pet and to document your written consent. Our team is happy to answer any questions you may have at any time while your pet is in our care.

Understanding Your Pet’s Periodontal Disease and Treatment

I understand and acknowledge the following:

• A complete and accurate evaluation of my pet’s teeth and gums requires general anesthesia and full-mouth dental radiographs.

• I understand that full-mouth dental radiographs will be performed on ALL of our dental patients and represent the current veterinary standard of care.

• Many dental diseases are not visible without radiographs. Additional findings may include, but are not limited to: periodontal disease, fractured or abscessed teeth, tooth resorption, retained roots, or oral masses.

• Treatment recommendations and final costs may change once my pet is anesthetized and a complete oral exam and radiographs are completed.

• My pet will be placed under general anesthesia to safely perform the complete oral health assessment and treatment. All anesthetic and surgical protocols are selected with my pet’s health, comfort, and safety as our top priorities.

• No guarantee has been made regarding the outcome of anesthesia or dental treatment.

• If the dental procedure is expected to exceed three (3) hours of anesthesia, it may be safest to complete treatment in multiple stages. This decision will be made by the veterinary team with your pet’s safety as the top priority.

• Some specialized procedures (such as root canals or crowns) are not performed at our facility. If indicated, we can refer you to a board-certified veterinary dental specialist.

• Certain dental conditions progress over time and can be painful. In some cases, proactive treatment such as extraction of a compromised tooth or treatment with localized therapies like Doxirobe gel may be recommended to reduce pain, infection, or future complications.

• Certain dental conditions progress over time and can be painful. In some cases, proactive treatment such as extraction of a compromised tooth or treatment with localized therapies like Doxirobe gel may be recommended to reduce pain, infection, or future complications.

Extraction Authorization

To minimize anesthesia time and avoid delays in care, please indicate your preference:

Proceed with extraction(s) of any diseased teeth deemed necessary for my pet’s health, understanding that fees may exceed the original estimate. I understand that dental extractions may, in rare cases, result in complications such as jaw fracture, changes in how the tongue rests or is supported within the mouth, and other cosmetic changes.

Contact me if the total cost is expected to exceed the high end of the estimate before proceeding with additional extractions.

HOSPITAL HUSBANDRY

If evidence of fleas are found on your pet, flea prevention will be administered for a fee.

ALTERNATIVES

I understand that reasonable alternatives, including no treatment, have been discussed with me. I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.

FINANCIAL RESPONSIBILITY

I agree to assume full financial responsibility for all services rendered. Treatment plans and estimates are not guaranteed. Payment is due at the time services are provided unless prior arrangements have been made.

REFERRAL OR TRANSFER OF CARE

If my pet’s condition fails to improve as anticipated and requires care beyond the capabilities of this facility, I understand that my pet may need ongoing monitoring and 24 hour care. I authorize referral or transfer to an appropriate emergency or specialty facility. I understand that transportation and referral costs are my responsibility and that the receiving facility will determine further care and fees.

NO GUARANTEE

I acknowledge that no guarantee or warranty has been made regarding the outcome, recovery, or results of any treatment or procedure.

CONSENT & AUTHORIZATION

By signing below, I certify that:

• I am at least eighteen (18) years of age

• I am the legal owner or authorized agent for this pet

• I have read and understand this consent form

• I voluntarily authorize the procedures described above and on the provided estimate