NEW Dental Consent Form

Dental Consent Form

Thank you for entrusting us with your pet's care! Please take a moment to complete this form for your pet's upcoming dental procedure and don't hesitate to contact us at 615-383-1000 or at info@belmontanimalhospital.com if you have any questions.
Account Holder's Name *

First Name Last Name
Pet's Name *
Primary Contact Name & Phone Number for Day of Procedure
First name, Last name & 10-digit phone number
Secondary Contact Name & Phone Number for Day of Procedure (someone authorized to make decisions for your pet in the event the primary contact cannot be reached)
First name, Last name & 10-digit phone number
Current Medications (including monthly preventatives)
Include name, strength, dose and frequency of medication; please be prepared to share the date and time the last dose of each medication was given when your pet is admitted.
Additional Requests or Procedures
Please understand that certain additional procedures will have to be approved by the attending veterinarian.
Please review the following options regarding teeth extractions and choose one option below:

If teeth extractions are indicated, I authorize all necessary extractions If teeth extractions are indicated, I would like to be called prior to extractions. If I am unavailable, I understand the decision for extractions will be at the doctor's discrection.
While your pet is under anesthesia, we can implant a microchip. Microchips have helped reunite thousands of lost pets. With a current annual membership (first year included with implant) the microchip also includes 24-hour emergency support, free poison control, and more. Would you like us to microchip your pet today? *

Yes No Already Microchipped
It is important that patient undergoing anesthesia be fasted before the procedure, while water is ok - all food should be withheld from your pet after 8:00p the night before the procedure.
By typing my name below, I hereby state that I am the owner or authorized agent for the owner of the animal identified above and authorize the veterinarians at Belmont Animal Hospital to perform such diagnostics, treatments, and/or surgical procedures as deemed necessary for my pet. The nature and risk of the procedure(s) have been explained to me and no guarantee has been made as to the results or cure. I fully understand that there may be risk and the potential for complications including death. I agree to pay, in full, for services rendered including those deemed necessary for medical or surgical complications or otherwise unforeseen circumstances and understand that an itemized estimate for the cost of the procedure(s) is available upon request. I have read the above conditions for treatment and acknowledge that I may have a copy of this form, if requested. *
Your name
Today's Date

Month Day Year
Should be Empty: