Teeth Cleaning Consent Form

Please complete the form with all the information requested.

First Name

Last Name

Email Address

Phone Number

Dog's Name

Breed

Age

I understand FurryDogmother will be using the Cleany Teeth ultrasound toothbrush on my dog which has no vibration, no movement and no noise. I understand FurryDogmother will be using the Cleany Teeth ultrasound toothbrush on my dog which has no vibration, no movement and no noise. I understand

I consent to the use of a tooth de-scaler on my dog’s teeth in a kind and gentle manner; to remove any loose tartar, plaque or stains from the teeth. I consent to the use of a tooth de-scaler on my dog’s teeth in a kind and gentle manner; to remove any loose tartar, plaque or stains from the teeth. I understand

I give my consent to the FurryDogmother taking before and after pictures to be displayed on the FurryDogmother' website or social media pages. I give my consent to the FurryDogmother taking before and after pictures to be displayed on the FurryDogmother' website or social media pages. I agree I don't agree

I understand that there may be some minor bleeding of the gums during and after teeth cleaning as the tartar and the plaque is removed. I understand that there may be some minor bleeding of the gums during and after teeth cleaning as the tartar and the plaque is removed. I understand

If the session must stop for any health or behaviour reasons, I will still pay for the full session taking place. If the session must stop for any health or behaviour reasons, I will still pay for the full session taking place. I understand

I understand that the FurryDogmother will stop the teeth cleaning session and I may need to seek veterinary assistance if:

Any loose teeth are suspected
If my dog objects and becomes stressed or aggressive.

Any obvious abnormalities are visible or suspected in the mouth such as:

A foreign body embedded in the mouth
Oral warts
Oral Injuries
Tumours

Whilst this method of dental cleaning is highly effective in removing mild tartar, improving gums and mouth health and breath, FurryDogMother cannot guarantee the treatments’ effectiveness or suitability for individual dogs due to varying external factors. FurryDogMother cannot be held responsible for any problems occurring from poor dentition before, during or after any ultrasonic treatments. Furry Dogmother ultrasonic treatment is not a veterinary procedure and Furry Dogmother cannot diagnose any problems with your dog’s mouth.

I Declare That I do not know of any medical reason why teeth cleaning cannot be carried out on my dog and I acknowledge that it is my responsibility to inform the FurryDogmother in the future should this be the case. I Declare That I do not know of any medical reason why teeth cleaning cannot be carried out on my dog and I acknowledge that it is my responsibility to inform the FurryDogmother in the future should this be the case. I agree

I hereby give my consent from this day forward to FurryDogMother to carry out, on my behalf, ultrasonic teeth cleaning on my dog. *