Dental Release Form - Oak Forest Veterinary Hospital

Client First and Last Name

Street Address

Street Address Line 2

City

State

Zip

Email

Mobile Number

Patient Name

Breed

Sex

Age

Color

Markings

I authorize Oak Forest Veterinary Hospital to perform the following procedures:

Procedure Described As

Factors that may limit our ability to detect every dental problem your pet may have with just an oral exam may include:

Lack of patient cooperation can impair visualization, especially of back teeth.
Many periodontal problems can be detected only by probing under the gum line with an instrument.
Dental tartar can hide underlying cavities or fractures.

If further problems are detected while your pet is under anesthesia, how should they be handled? (choose one)

Do whatever is necessary to give my pet a healthy oral cavity.
Please contact me by my phone number below before doing any additional dental procedures.

If I can’t be reached by phone while my pet is under anesthesia, then: (choose one)

Perform whatever procedures are needed.
Do only what I have authorized. I understand that additional dental work needed will require another anestheticepisode to complete the dental treatment.

Pre-operative blood work assists us in evaluating your pet's health to reduce risk associated with your pet undergoing anesthesia and is mandatory. If blood work is not done before today, the cost for pre-operative bloodwork is $100.26

I would like any remaining baby teeth to be extracted, if possible, during surgery.

Yes
No

Would you like your pet to be microchipped while under anesthesia today? (For a $60 additional cost)

Yes
No

Should an unexpected critical situation arise (choose one)

I authorize and accept financial responsibility for the veterinarian (s) and staff to perform lifesaving procedures.
I choose that the veterinarian(s) and staff DO NOT resuscitate my pet

If fleas are found on my pet, I understand he/she will be treated with Capstar. I consent to the administration and use of anesthesia. I agree to pay in full for all services rendered including those deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. I understand that subsequent procedures or complications including but not limited to anesthesia, repair of surgical sites, antibiotics, or wound management are not covered by initial surgery cost. The nature and purpose of the procedures, possible alternative methods of treatments, risks involved, and possibility of complications have been fully explained to me. I acknowledge that no guarantee or assurance had been made as the results that may be obtained.

Accept Terms

I accept that you have read and understand all the above information.

Name

Signature Date