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Dental Radiograph Form

In an effort to reduce your pet’s time under anesthesia, we would like to preemptively go over common questions that may arise during your pet’s dental procedure. It is not possible to do a full assessment of your pet’s teeth prior to anesthesia, therefore we often find dental issues
that we could not predict in the exam room that require dental radiographs and possible extraction. Please be aware, you will need to be available via phone the entire day. If we are unable to reach you to discuss the recommended treatments, we will not pursue any additional therapies unless you specify otherwise below. If we are unable to reach you, we will complete the dental cleaning and recover your pet from anesthesia.

Do you give permission for the doctor to take radiographs of diseased teeth? This will add between $44.55-164.90 depending on how many radiographs are necessary.(Required)

YES – I give permission to proceed with any necessary radiographs

NO – I would like a call to discuss any pathology prior to radiographs

Do you give the doctor permission to extract any recommended teeth? Depending on the degree of disease and the number of extractions, this could add $50-$650 to your invoice.(Required)

NO – I would like a call before any extractions are completed

Yes – I give the Doctor permission to extract diseased teeth

Phone number to reach you today(Required)

Date(Required)

Name/Signature(Required)