Dental Form

Name of Owner

Name of Pet

Age

CanineFeline

As your pet's health is our utmost concern, during dental cleanings we may find teeth that are in need of further examination and treatment. We offer digital dental radiography (X-rays) to assess the health of the teeth, including the root structure and surroundingbone. X-rays may be needed to help us provide treatment or extraction.

Call before any x-rays or extractions are done.Perform x-rays at the doctor's discretionExtract teeth at doctor's discretionPlease do full mouth x-rays ($125) regardless of the oral exam findings to full assess my pet's oral health

Dental Radiograph Pricing:

1 x-ray $52.11

2-4 x-rays $103.14

5+/Full Mouth x-rays: $147.25

The cost of oral surgeyr is dependent upon the length of time needed to remove oral masses and/or diseased teeth.

Oral surgery duration/pricing:

30 minutes: $292.21

60 minutes: $584.42

Additional 30 minute incriments: $292.21

If your pet needs extensive surgical attention, the doctor may elect to do surgery in multiple stages (typically 2-3 visits, each requiring anesthesia). Depending on the location of oral surgery, 1-4 nerve blocks may be required ($26.50/each)

**Prices are subject to change. Please refer to your estimate for more detailed pricing. PLEASE CONTACT US IF YOU DID NOT RECEIVE AN ESTIMATE.

Do the necessary x-rays and/or extraction(s) based on the doctor's discretionDo NOT do any x-rays or extractions and recover your pet form anesthesia WITH the KNOWLEDGE that further anesthesia may be required at a later date.

Signature of owner/agent

Date

Phone number where you may be reached TODAY

Format: (000) 000-0000.

Alternate phone number

Format: (000) 000-0000.

May we text this number?

GENEVA LAKES ANIMAL HOSPITAL