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Owner's Name

Pet's Name

Email Address

Phone

note

*Phone number for contact during procedure:

Immediate availability to a phone call is imperative to the safety of your pet, so please leave a reliable number you will be free to answer and we will contact you.

terms

In the interest of your pet's optimum health and quality of life, we will be providing a dental health procedure today. A full dental health procedure is not a simple teeth cleaning; on the contrary, it is a full anesthetic procedure often involving invasive actions. The standard dental procedure involves, but is not limited to:

Full general anesthesia with intubation
ECG, respiratory, and pulse oximetry monitoring
Deep oral exam, well beyond what can be provided while awake
Ultrasonic scaling
Polishing
Dental radiology

During the procedure, if findings indicate necessity of additional services (extractions, periodontal treatments, etc), the doctor will provide the extra care, but it will be at an additional cost. If the doctor encounters needs beyond the above list, please advise us below how you would prefer we proceed.

I understand that if I cannot be reached within 10 minutes, the recommended additional services will not be performed and my pet will be recovered from anesthesia. A new appointment will need to be made for the recommended services to be performed, at which time $98.60 will be charged for the additional anesthetic procedure.

I extend authority to the doctor to provide all additional services that are found to be necessary at additional cost to me.
Please call me for consent before performing any additional treatment on my pet.

We always contact clients when their pets are awake from anesthesia. Please indicate below your preferred method of being contacted.

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I have read and approve of the terms stated above.

I accept these terms.

Today's Date