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

Consent(Required)

My pet needs to be fasted the night prior to the procedure. (*No food after 12:00 AM, but water is OK until the time of drop off.)(Required)

Consent(Required)

Veterinary dentistry is not an exact science and that guarantees of outcome are not possible. Treatment options and procedures have been explained to my satisfaction and I consent to carry out these treatments.(Required)

Consent(Required)

The ultimate success of the proposed treatment may depend on adequate home-care and follow-up, and I acknowledge my responsibility in this regard. This is particularly so with periodontal disease.(Required)

Consent(Required)

Any anesthetic procedure poses some risk to the patient and that precautions will be taken to minimize such risks. In the unlikely event of an anesthetic complication, I authorize Shiloh Animal Hospital to carry out procedures deemed appropriate, and I realize that I will be responsible for such charges.(Required)

Consent(Required)

My pet may be photographed for the purpose of documenting the treatment and the photographs may be used for educational purposes. Confidentiality is assured.(Required)

Consent(Required)

Dental extractions, if found to be necessary, may be performed on my pet and I will be responsible for any additional costs associated with such extractions.(Required)

Consent(Required)

The estimate given is only an estimate and is based on a pre-anesthetic examination. Undetected abnormalities may become apparent during the more detailed oral examination or on the radiographs taken during anesthesia, invalidating the previous estimate. I recognize that additional procedures may be required.(Required)

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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