Dental Release Form Dental Release Form Name(Required) First Last Primary Phone Number(Required)Secondary Phone NumberPet's Name(Required) Pet's Name Species(Required)DogCatAuthorization of procedures and liabilty release(Required) I consentI, the undersigned, do hereby certify that I am the owner, or duly authorized agent for the owner, of the animal named above. I do hereby give Dr. Evelyn Tom, Singing Hills Animal Hospital, Inc., their agents, relief veterinarian, servants, and/or representatives full and complete authority to perform the following procedures described as: anesthesia, dental scaling, polish, and sealant. While under anesthesia, your pet's teeth will be probed and determined if there are broken or abscessed teeth. Additional dental procedures may be adviseable and useful to promote or protect the health of the above described pet. I realize that these additional procedures will incur additional expense. I do hereby release the said doctors, Singing Hills Animal Hospital, their agents, servants, and/or representatives from any and all liability arising from said dentistry, surgery, and/or sedation/anesthesia, on said animal.For the safety of our patients, an intravenous catheter and fluids are required in anethestic procedures. This increases safety by keeping blood pressure higher, increase perfusion of vital organs, increase speed of clearance of anesthesia, and aid in life saving protocols.(Required) I understand Dental radiology is currently available and may be recommended. If dental root pathology is suspected, I authorize dental radiology of the quadrant of the mouth affected. I understand additional costs will incur.(Required) I consent In the event of severe dental disease, full mouth radiology may be recommended. I authorize full dental radiology. I understand additional costs will incur.(Required) I consent I understand pain medications, antibiotic injections, and/or nerve blocks may be given at additional charge, if needed, as determined by the veterinarian.(Required) I understand I understand my pet may be prescribed antibiotics and/or pain medication as determined by the veterinarian.(Required) I understand I understand extractions may be necessary at an additional fee of $30-299 per tooth. I understand that declining extractions leaves my pet at risk for infection, systemic complications, pain, and difficulty eating. Should extractions be declined against medical advice, Singing Hills Animal Hospital will not be responsible for resulting complications. Should I decide at a later time to have recommended extractions performed, my pet will require another anesthetic procedure at my expense.(Required) I understand I certify my pet has not eaten within the last 12 hours.(Required) I understand I understand my pet is fasted for an anesthetic procedure, however, if an anti-nausea medication is needed, there will be an additional fee of $70-$200.(Required) I understand I understand my pet must be current on vaccinations. If determined by record or examination that my pet is due for vaccinations, I understand vaccinations will be performed at my expense. I understand treatment for external or internal parasites, including fleas, is mandatory if found on my pet.(Required) I understand I understand that Singing Hills Animal Hospital is not responsible for any items I may leave, such as collars, leashes, toys, and blankets.(Required) I understand Additional Dental Services(Required) I have read and understood the following statement.I understand that 60% of the tooth structure is below the gum line and the full extent of my pet's dental needs can only be determined with a complete oral examination and dental x-rays while under anesthesia. I understand that extractions may be required at an additional fee of $30-$299 per tooth. Should any unforeseen dental procedures be necessary in the veterinarian's professional judgment and I cannot be reached on the phone number I provided, I understand I am responsible for any fees incurred during the course of my pet's treatment. In order to minimize time spent under anesthesia, please choose from the following options:(Required)I prefer that you proceed with all necessary dental procedures. I do NOT need to be contacted prior.I prefer that you proceed with all necessary dental procedures so long as they do not exceed the total procedure cost expectation. If treatment will exceed this amount, please contact me first for prior approval.Total Procedure Cost Expectations(Required)Please enter your expected total procedure cost. We will contact you if projected treatment costs will exceed this amount.By checking this box and signing below, I certify that I am the rightful owner of the above named pet and agree to the above Terms and Conditions(Required) I agree Owner's Signature(Required)
