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*

I extend authority to remedy conditions that are not known at the time the procedure is commenced, but are necessary in the Doctor's opinion and will incur all cost associated with the treatment performedPlease call me if total cost of treatment exceeds $__________. I understand that if I cannot be reached, my pet will be recovered from anesthesia without all necessary treatment performedPlease call me before performing any additional treatment on my pet. I understand that if I cannot be reached, my pet will be recovered from anesthesia without all necessary treatment performed
Call if total cost of treatment exceeds*
Person Signed: (Owner of animal or authorized agent)*

Clear
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

Microchip-Home Again (includes Registration) - $57.50Standard Nail Trim - $13.50Dremel - $ 25.50Standard Ear Cleaning - $18.70Anal Glands Expression: $18.20Face Trim - $18.20
Should be Empty: