K9 GENTLE DENTAL CLIENT CONSENT FORM  

All animals – in particular older ones - can have unknown underlying health issues and there are always

risks involved while working with animals as they can be unpredictable. K9 Gentle Dental will take every precaution when handling your pet to do our very best to keep them safe while they are in our care. Your pets’ wellbeing is extremely important to us. In order to work on your pet, we will need this form completed and signed.

By signing this form, I ______________________________________, the pet owner, acknowledge that there are

inherent risks to my pet in the performance of these services, including, but not limited to, cuts, abrasions, infection, illness, stress, or adverse reaction to any of the cleaning agents used.

I agree that the services provided by K9 Gentle Dental are provided solely at my risk, and hereby waive and release K9 Gentle Dental, its directors, officers, employees, shareholders, volunteers, representatives, agents and the host business and its employees and representatives (the “Released Parties”) and indemnify and hold the Released Parties harmless from and against any and all liabilities, claims, demands, causes of action, judgments, costs or expenses (including legal expenses) which K9 Gentle Dental or the Released Parties may suffer, sustain or incur as a result of any act or omission of any nature or kind whatsoever arising out of, or in the course of the performance of the Services, including without limitation, negligence, breach of contract or breach of duty of care.

I understand and acknowledge that the representatives of K9 Gentle Dental are not veterinarians and will not perform any veterinary medicine. I understand that sedation free cleanings are a hygienic service and not meant to replace visits to your veterinarian. Initial:__________ Your Name: ______________________________________ Phone: ________________________________________ Your Address: _____________________________________________________________________________________ Alt Phone #: ______________________________ Email: _________________________________________________ By providing my email and signing below I authorize K9 Gentle Dental to use my email address to contact me regarding my future appointments

#1 Dog Name: _________________________ Age: ________________ Breed: ____________________________ #2 Dog Name: _________________________ Age: ________________ Breed: ____________________________ Any Health Issues: Date of last cleaning: Has your dog every bitten anyone before? Can your dog have coconut oil? How did you hear about K9 Gentle Dental? I have been informed that my dog may have dental issues that should be seen by a veterinarian. I have been informed that a sedation free cleaning may not be sufficient for my dog to maintain their oral health. I understand that there are limitations to sedation free cleanings, including the lack of any diagnosis or treatment. I have chosen to continue with a sedation free cleaning, which may leave underlying issues unresolved.___________ Total cost: I have read & understood the above information and authorize payment noted above: Signature: _____________________________________________ Date: ______________________________

K9 GENTLE DENTAL CLIENT CONSENT FORM  

CLINIC DATE + LOCATION: Dog Name: Dental Tech: Grade: Next Cleaning: Notes: Loose Teeth Upper - Left: Right: Lower – Left: Right: Missing Teeth Upper - Left: Right: Lower – Left: Right: Gum Recession Upper – Left: Right: Lower- Left: Right: Staining- Gum health- Tartar levels- Crowding-

Biter____ Clamper____ Anal Glands____ Poo____ Pee____ Male/Female Other: