Dental Release Form - Erlanger Veterinary Hospital

Date *

Owner's Name *

First

Last

Pet's Name *

I hereby authorize Erlanger Veterinary Hospital and its designated associates, technicians or assistants to treat, anesthetize, prescribe medications for, and perform specified diagnostic tests or surgery on my pet. *

I have read and authorize.

I understand the risks associated with these procedures know that all reasonable precautions will be taken against injury, escape, or destruction of my animal and will not hold Erlanger Veterinary Hospital responsible in event of such. *

I have read and understand.

In the event that hospitalization is recommended, I understand that my pet will not be monitored by the veterinary staff outside of normal business hours. I also acknowledge that the option to transfer my pet to an emergency care facility for continuous monitoring was discussed as an alternate option. *

I have read and understand.

If emergency treatment is required and I cannot be reached, I authorize Erlanger Veterinary Hospital to perform such procedures as are necessary to preserve the life of the patient until I can be contacted. *

Yes, I authorize.
No, I do not authorize.

We have recommended a dental cleaning for your pet based on a physical exam. Once anesthetized, we can perform a more thorough oral examination and dental x-rays to better determine the extent of oral disease. At that time, we may find it necessary to perform additional dental procedures such as periodontal treatments to promote health at the gum tooth interface, and if severe disease is present, we may recommend extraction of the affected teeth. Please initial the appropriate response on the lines below: *

Yes, I authorize these additional procedures as deemed necessary by the doctor and understand that I am responsible for the associated cost.
No, I prefer to be contacted with an estimate of cost for additional procedures. In the event that I cannot be reached, I do not authorize additional procedures.

***MUST BE ACCESSIBLE BY PHONE OR E-MAIL FROM 8:00am – 5:00pm TODAY!!!***

Please list any medications your pet has received in the past 24 hours and the times they were given.

Our hospital is a “Flea Free Zone”. All pets will be checked for fleas upon admission. If we find live fleas on your pet, they will be treated at an additional cost. *

I have read and understand.

I am the owner or authorized agent of the owner of the pet presented for care. I accept financial responsibility for treatment of the above-named patient and understand that payment in full is due upon release of my pet from the hospital or when service is otherwise terminated. I certify that I have read, fully understand, and agree to this authorization. *

I have read and agree.

How would you like to be notified when surgery has been completed? *

Phone
Text Message
E-mail

***MUST BE ACCESSIBLE BY PHONE OR E-MAIL FROM 8:00am – 5:00pm TODAY!!!***

Phone # where I can be reached TODAY *

Alternate Phone Number

Cell Phone # (for Text Alert Only)

E-mail Address (for E-Mail alert Only)

Signature *

Clear Signature

*

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