Dental Cleaning & Oral Surgery

Pet Owner / Caretaker(Required)

First Last

Primary Contact Number(Required)

Secondary Contact Number(Required)

Pet's Name(Required)

Date of Scheduled Procedure(Required)

Procedure(Required)

Additional Procedures or Concerns(Required)

I understand ALL of the following

I understand and agree to ONE of the following(Required)

I authorize testing and treatment as outlined on the estimate given and place no limit on additional charges/services carried out at the doctor's discretion, including but not limited to extractions.

I authorize treatment as outlined on the estimate given and approve charges up to an additional specified dollar amount (specify in the space provided below).

Please call me with a revised estimate before performing any additional procedures not outlined on the estimate given. If I cannot be reached, I authorize additional treatments deemed appropriate by the veterinarian, including but not limited to extractions.

Please call me with a revised estimate before performing any additional procedures not outlined on the estimate given. I understand that if I cannot be reached, my pet will receive NO treatments, except in the case of an emergency, other than those outlined on the original estimate.

Other

I have reviewed the above material. I have had all my questions answered and fully understand the procedures to be performed and the associated risks.(Required)

I understand that Shiloh Animal Hospital is not staffed overnight.

Please be advised that the pick-up time will be determined by the number of procedures we have, your pet's recovery, and your pet's procedure. Pick-up is frequently early to mid-afternoon, although we will contact you after the procedure to schedule a more precise time.

As the owner or agent of my pet, I hereby give my consent to Shiloh Animal Hospital to perform the above said procedure(s).

CAPTCHA

I understand ALL of the following

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