Dental Release Form

I, 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.

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.