Dental Anesthesia Treatment Form

Dental Anesthesia Treatment Form
Please fill out all of the required form fields below. Your submission will autopopulate a PDF which will be sent to our staff for review.
Date

MonthDayYear
Date
Pet Name
Pet Owner Name

First NameLast Name
Vaccination Initials
Rabies is required for all patients undergoing treatment. I understand this requirement and authorize vaccination of my pet if he/she is due for Rabies.
Bloodwork Initials
Pre-anesthetic blood for patients under the age of 7 years is optional ($77.60) Cost of pre-anesthetic blood work is built into the estimate for patients over the age of 7 years. I understand these conditions and approve of pre-anesthetic blood work for my pet.
In the event that I cannot be reached, please check ONE of the following boxes
Call if total cost of treatment exceeds
Person Signed: (Owner of animal or authorized agent)
Date Signed

MonthDayYear
Date
Phone Number where you can be contacted

Area CodePhone Number
Pet Food/Water Initials
Please initial if the pet has had no food or water for the past 10 hours
Procedure Estimate Initials
Please initial if you have received an estimate for the procedure and approve the treatement listed
Authorization to Treat Initials
For the health and safety of all of our patients, any animal on premises with signs of fleas will be treated at owners expense.
Check if you would like any additional services
Should be Empty: