Dental Consent Form Dental Consent Form Owner's Name * Owner's Name First First Last Last Date * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email * Home Phone * Cell Phone Work Phone Phone Number you can be reached at today * Pet's Name * Breed * Color * Age * Sex * Weight * “Our hospital policy is that we treat your pet as if it were our own” Has this pet received any food or water since 9:00 pm last night? * Yes No If yes, please inform the receptionist. Is this pet currently on any medications? * Yes No If Yes, please list * Has this pet ever bitten, scratched, or shown aggression toward anyone in any situation? * Yes No If Yes, please explain * Does your pet prefer * Dry food Canned food What brand of food do you feed your pet? * How Much? * Anything beyond a basic cleaning can be expensive. Extractions can cost from $12 to $200 per tooth. In the event that dental extractions, minor dental surgery or dental x-rays are discovered to be needed during my pet's dental cleaning, I authorize the following: * I authorize the veterinarian to do any extractions, x-rays, or procedures deemed necessary while my pet is under anesthesia. Please attempt to contact me if anything additional is needed but proceed if I am not available. Please contact me regarding any additional procedures. If I am not available, do not proceed. I understand this may mean my pet will require an additional procedure under anesthesia at a different time. Please list any additional services requested I understand the explanation you have given to me of the nature and purpose of the treatment, the risks involved, and the possibility of complications. I acknowledge that no guarantee has been made to me as a result of this procedure. PAYMENT IN FULL AT THE TIME OF DISCHARGE IS EXPECTED If any pet is not claimed within several days after the time specified for discharge and if the doctor is not notified in writing of an alternate date within the seven day period, the pet will be considered abandoned and become the property of Limerick Veterinary Hospital. LVH will decide what is in the best interest of the pet and its future. Abandonment of any pet does not relieve the owner/responsible party from any bill that may have been incurred for services/procedures performed on the pet after admittance to the point of abandonment. Should it be necessary to assign this account to a licensed collection agency or attorney, the owner/responsible party agrees to pay all subsequent collection and/or legal fees. I, being responsible for the above described animal, have the authority to grant you my consent to receive, prescribe for, treat and operate upon my pet. Signature of Owner or responsible party * signature keyboard Clear If you are human, leave this field blank. Next
