Dental Consent Form

Ensure your pet receives safe, thorough dental care at Victoria Veterinary Clinic. Please complete this form before your pet’s scheduled procedure and provide any relevant medical history or concerns.

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Two dogs, one black and tan with pointy ears and the other fawn-colored with floppy ears

About Our Dental Procedures

Our dental services include cleaning, polishing, and extractions if needed. While under anesthesia, your pet will receive intravenous fluids to support circulation, post-operative pain management, and an oral anti-inflammatory for at-home care. Photos can be taken before and after the procedure, and optional services such as microchipping or growth removal can also be performed during the same visit.

Complete the Form

Consent Form for Dental Procedures

Date of Dental Procedure(Required)

MM slash DD slash YYYY

Client Name(Required)

First Last

Email(Required)

Patient Name(Required)

Is your pet fasted?(Required)

Yes

Is your pet on any medications?(Required)

Yes

Medication Name

If your pet is taking multiple medications, list them all here.

Medication Dose

If your pet is taking multiple medications, list the dose for each medication.

Medication Last Given

If your pet is taking multiple medications, list the date each medication was last given.

Any signs of illness?(Required)

Yes

If yes, would you like an exam done? Cost: $104.50(Required)

Yes

Concerns(Required)

Dental Cleaning and Polishing with Possible Extractions

If Extractions: Often the full extent of extractions is not known until your pet is fully anesthetized and an oral exam can be performed. In the event your pet needs extractions, how would you like us to proceed.(Required)

Call to discuss any unexpected extractions before proceeding

Pull any teeth deemed necessary

Pull any teeth deemed necessary up to a specific $ amount

Up to $(Required)

Pre-dental and post-dental photos will be taken. Would you like them?

No Photos

E-mail Photos

Preferred email address:(Required)

Any other procedures requested:

Growth Removal

Would you like the growth sent for analysis?

Yes (additional fees apply)

Location of lump(s):

Intravenous fluids will be administered during anesthesia to help maintain blood pressure, increase circulation and help your pet recover more quickly.

A 24-hour injectable pain medication is given post-operatively. Your pet will also be sent home with three days of an oral anti-inflammatory medication to be given at home to reduce pain and inflammation.

Surgical Options (Check Accept or Decline)

Presurgical blood test for pets under 7 years - Cost: $89.50

Decline

Checks for proper organ functions, oxygen carrying ability of blood, ability to fight infection, platelets for proper clotting and to establish a baseline for future reference.

Presurgical blood test for pets 7 years and older - Cost: $131.50

Decline

Same as the presurgical blood test above but includes more extensive testing.

Elizabethan Collar - Cost: $9.60-48.99

Decline

Prevents licking or chewing of the incision area.

Medical Shirt - Cost: $40.06-46.95

Decline

Prevents licking or chewing of the incision area. These are not needed for dental procedures but may be used for some growth removals.

Pedicure - Cost: No Charge

Decline

Nails are clipped while your pet is anesthetized.

Vaccinations - Core vaccines: $104.50-134.50

I authorize vaccines

My pet is vaccinated

I decline vaccines at this time

I authorize the veterinarians and staff at Victoria Veterinary Clinic to perform cardiopulmonary resuscitation (CPR) (including chest compressions, intubation, and emergency medications) in the event of a respiratory or cardiac arrest. (Fees apply)(Required)

Decline

I authorize and direct the Veterinarians of the Victoria Veterinary Clinic to perform the services indicated above and/or do any other therapeutic procedures that in their judgment may dictate to be advisable for my pet’s well-being. The risks and nature of the procedures have been explained to me, and no warranty or guarantee has been made as to the result or cure.(Required)

I hereby authorize and direct the Victoria Veterinary Clinic to provide such additional services for my pet as they deem reasonable and necessary, including, but not limited to the administration of anesthesia and the performance of services involving pathology and radiology, and I hereby consent thereto.(Required)

Fees must be paid before my pet leaves the clinic.(Required)

Contact Information

I may be reached at the following number(s)(Required)

Would you like a text message photo update of your pet?

Yes

Number(Required)

Name

First

Signature(Required)

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Request an Appointment Today

Victoria Veterinary Clinic offers full-service veterinary care for dogs and cats in Regina, SK, as well as nearby areas like White City, Pilot Butte, Lumsden, Emerald Park, and East Regina. As a Fear Free Certified clinic, we focus on reducing stress while providing expert care in wellness, surgery, diagnostics, dentistry, and cat boarding. Ready to get started? Request an appointment below.

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Have a Question?

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Location

Victoria Veterinary Clinic
628 Victoria Ave
Regina, Saskatchewan S4N 0R1

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Contact

Phone: (306) 522-8802
Email: vvetclinic@gmail.com

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Hours

Monday – Thursday: 7:30 AM – 7:00 PM
Friday: 7:30 AM – 6:00 PM
Saturday: 9:00 AM – 4:00 PM
Sunday: Closed
Statutory Holidays: Closed

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First Last

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