Dental Consent Form

Please fill out this form prior to your visit.

I, the undersigned owner or owner's agent of the pet named certify that I am eighteen years of age or over. I have been informed that my pet is in need of preventive or therapeutic dental care and consent to the appropriate procedures described to me by staff veterinarians at The Pet Hospital of Tierrasanta. These procedures include but are not limited to the following: 1) dental prophylaxes (routine teeth cleaning and polishing), 2) extractions, 3) gingival flap surgery to close gaps left by extractions, 4) root planings, 5) dental radiographs, and 6) antibiotic gel implants.

I am aware that dental procedures for animals require the use of anesthesia to: 1) maximize visualization of the gums, teeth, and oral cavity, 2) minimize movement and discomfort, 3) allow for subgingival (under the gum) cleaning, and 4) provide for the safety of the pet, doctors, and hospital staff. I understand that some risks always exist with anesthesia and dental procedures such as allergic reactions, jaw fractures, heart problems and death. I an1 encouraged to discuss any concerns I have about those risks with the attending veterinarian before these procedures are initiated. Should some unexpected life-saving emergency care be required and the attending veterinarian be unable to reach me, the staff has my permission to provide such treatment and I agree to pay for such care.

I have been informed that examinations under anesthesia often reveal abnormally loose teeth that fall out or should be extracted to prevent oral discomfort and ongoing infection of surrounding bone. I also have been informed that the loss or removal of one or more unhealthy canine teeth occasionally allows for an awkward protrusion of the tongue to one side or the other. Nevertheless, all questions and concerns I have about the recommended dental procedures have been answered to my satisfaction. I understand that an estimate of the fees for the above dental care will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered. I assume financial responsibility for these fees, and will provide payment via cash, credit card, or check at the time my pet is discharged. I agree to pay a monthly billing and financing fee equal to 1.5% of any unpaid balance.

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We've proudly served the pets of Ithaca, NY for over 30 years.

Your pets are as important to us as they are to you, and we strive to demonstrate that in all that we do. Your dog or cat deserves the best veterinary care.

Contact Info

Phone: 607-273-3133
Fax: 607-238-2363


712 W Court St.
Ithaca, NY 14850
Click here for directions.


Mon - Fri: 7:30 am - 6 pm
Sat: 8 am - 12 pm
Sun: Closed

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