Dental Check In (Custom PDF)

Pet's Name*

Date and time of appointment*

Date

Time

Primary Contact Name*

First Name Last Name

Primary Contact Name*

Primary Contact Cell Number*

Please enter a valid phone number.

Secondary Contact Name

First Name Last Name

Secondary Contact Number

Please enter a valid phone number.

What flea and parasite control is your pet currently on?*

When was the flea and parasite control last given?

Has your pet experienced any changes in urination or defecation?*

YesNo

Has your pet experienced any changes in behavior?*

YesNo

your pet on any medications, supplements or vitamins? Please list all, and when they were last given*

Is there anything else we should know before we see you and your pet?

Anesthetic and surgical procedure to be performed*

I the undersigned owner or agent of the owner of the pet identified above, certify that I am eighteen years of age or older and authorize Crescenta Canada Pet Hospital to perform a Comprehensive Oral Health Assessment with Dental Scaling and Polishing. understand that during the performance of the above dental procedure unforeseen conditions may be revealed that require additional treatment. These treatments may include removal of teeth, gum tissue and/or jawbone or portions there of. I understand that no healthy teeth, gum tissue, or bone will be willfully removed other than that which is required to insure the health of the surrounding teeth/tissue/bone or to further the health and pain relief of the pet. Therefore, I consent to and authorize the performance of such dental procedures and/or operations as necessary in the veterinarian's professional judgment. I also authorize the use of appropriate anesthetics and other medications. have been advised as to the nature of the dental procedure and/or operation and the risks involved. I understand that some risks always exist with anesthesia and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is initiated. I realize that results cannot be guaranteed. I realize and understand that if the removal of teeth, tissue or bone is required, or if further dental procedures or operations are required, additional expenses will be incurred.

Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, select the following answer:*

The doctor HAS my permission to provide such emergency treatment and I agree to pay for such servicesThe doctor DOES NOT have my permission to provide such emergency treatment

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I agree to financial responsibility for the remaining fees and will provide payment via cash, check or credit card at the time my pet is discharged from the hospital.

If additional procedures are recommended or required while my pet is under general anesthesia today, I understand the doctor will contact me at the numbers written above. If I cannot be reached within 10 minutes, this is how I want the veterinarian to proceed.*

Do whatever is necessary for the health of my petDo NO further treatment. I realize that if treatment is needed at a later time, I will incur further anesthesia and treatment costs. I also realize that tooth loss can occur without extraction if periodontal disease is present.Or, continue with treatment as long as the TOTAL charges do not exceed the following amount. I understand that any future treatment will be an additional expense.

Amount not to exceed

Our team at Crescenta Cañada Pet Hospital is here to help you care for your pet in the best manner possible. We are always here for you and your pet. Our veterinary team is committed to our values of Empathy, Compassion, Understanding and Open Communication. We ask that you partner with us and share in these values. We will not tolerate yelling, swearing or any type of abuse to our team. If something is not right, we want to help address it, in a respectful manner.

Sincerely,

The Doctors and Team at Crescenta Cañada Pet Hospital

I have read and fully understand the terms and conditions set forth above.

By signing below you are confirming your appointment. We look forward to seeing you and your pet!*

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