Winchester Animal Hospital

901 North Loudoun Street
Winchester, VA 22601



Dental Consent


Please forward all previous records to



Dental Consent Form

Dental Prophy Consent Form For (Pets Name): (required)

Today's Date: (required) :

I hereby authorize and direct the veterinarians of the Winchester Animal Hospital to perform a dental prophylaxis on my pet. I understand that any additional procedures and/or treatments may increase the final cost. I understand that the hospital requires all pets be current on their vaccinations, be free of all parasites, and have had a recent physical examination. I realize there is always a risk when anesthetics and other medications are used and when a dental is performed. I also know that results cannot be guaranteed. The doctors have my permission to do what they view necessary for my pet today.
I understand that some unhealthy teeth may fall out on their own during this dental procedure.
My pet has had nothing to eat in the last 8 hours.
Payment is due when pet is picked up from surgery. Do you understand and agree?
Owners Name: (required)
First Name (required)
Last Name (required)
Where can we reach you today? (required)
Phone TypePhone Number (required)
E-Mail Address (required) :
Owners County (required)

Pre-Anesthetic Blood Testing and Healthy Heart Check
Our greatest concern is the well-being of your pet. Before putting your pet under anesthesia, we can perform a blood analysis. This gives us an inside look at your pet’s vital organs and lets us know if they are functioning normally. Such tests are important before any kind of surgery. We strongly recommend that you have the blood work done at any age, but if your pet is over six years old we do require a MINI chemistry panel be performed. If your pet is over eight years old we do require the full blood PROFILE to be done. We can also check your pet’s heart by the use of an ECG. This will insure us that your pet has a strong and healthy heart before going into surgery. Ask for the lab’s current prices.
I would like the MINI panel done for my pet’s safety (6 chemistry panel-PCV-Total protein)
I would like the FULL PROFILE done for my pet’s safety (12 chemistry panel -PCV-Total protein-CBC)
I would like an ECG done on my pet to insure a healthy heart before surgery is done today.
Microchipping is recommended in all pets. The procedure is more comfortable while you pet is under anesthesia.
The fee includes insertion of the microchip and registration with HomeAgain Pet Service. MicroChip ID and Registration - $56.00 (required)


If my pet has unhealthy gums and an antibiotic treatment medically placed under the gums could help heal the gum and help prevent my pet from loosing that tooth, please do the treatment for an extra $72.00 (required)


If the doctor finds something unexpected during surgery I would like the following steps taken: (required)
Call Me
If you cannot reach me then: (required)

Perform the services for my pet that the doctor deems fit within (price range below)
Do not perform any extra services to my pet.
You do not need to call me, do what is best for my pet within (price range below)

If you cannot reach me, my max price range addressed in the question above is: (required)

I agree that I have read all of the information provided on this form and that all of the above information I have provided is true. (required)

Yes, I agree

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