Consent Letter For Dental Cleaning Under General Anesthesia

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In this case, representing as the owner or authorized agent of the owner with full ownership right (further mentioned as a patient’s owner) of the pet described below:


I herewith declare that I fully agree and grant the Groovy Vetcare Clinic to provide dental cleaning and/or comprehensive oral health assessment under general anesthesia procedures for my pet (further mentioned as a patient). I understand that although all procedure(s) will be performed to the best of the abilities of the professional staff, no guarantee or warranty can be made regarding the results or cure, so I will not hold Groovy Vetcare Clinic, the veterinarians, or any staff liable if any undesirable circumstances occur. I have had opportunities to discuss with a veterinarian until I obtained satisfying explanations regarding indications, procedures, goals, risks, complications, prognosis, alternatives, and other circumstances related to the treatment for the patient, which I fully understand and agree with, such as:

  • Dental cleaning and/or comprehensive oral health assessment procedures require general anesthesia. There are always inherent risks associated with anesthesia, including complications or death, even in apparently healthy animals. As the veterinarian intends to minimize these risks, pre-anesthetic blood test(s) are required to check the status of internal organs and other indicators that can be used as parameters to evaluate the risks of anesthesia and dental cleaning procedures for the patient.
  • One or more legs shaved in order to place IV fluids need to be done as the veterinarian intends to maintain blood pressure, increase circulation, and allow rapid administration of injection drugs during and after the patient undergoes the procedure.
  • Teeth removal and/or oral surgery needed to be performed for teeth or tissues that are damaged or decayed, which can trigger other diseases further if ignored. These procedures can be associated with inherent risks such as broken tooth roots, bleeding, damage to surrounding tissues, fractures of the jaw, and other unforeseen risks.
  • Dental radiographs (x-rays) are occasionally used by the veterinarian in order to better evaluate the patient's tooth structure, tooth root, and other tissues below the gum line and cannot be seen on gross examination. Extracting a tooth without a dental radiograph has the risk of causing disease complications for the patient.

I understand and accept that the information I obtained before the anesthetic procedure was performed on the patient regarding the plans mentioned above could evolve and also differ from the final results after. It correlates to problems that may not be revealed until a thorough examination and diagnosis under general anesthesia is performed. I declare further that I am willing to bear all costs incurred to any estimated fees already identified and agreed upon by me, as well as other expenses that arise from undesirable circumstances from the risk of the procedures. And I will obey the Groovy Vetcare Clinic’s payment policies.



  • The minimum deposit is IDR 2.000.000, added to the total cost of the initial examination fee, treatment(s), diagnostic test(s), medication(s), and laboratory test(s) that have been done before the procedure. The estimated cost of the procedure provided is an estimation and may change according to the patient's condition during and after undergoing the procedure.
  • Payment in full is required at the time of patient discharge.
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