Dental Admission Form

Dental Admission Form
Please provide at least 24 hours prior to appointment
Dogs/Cats: Please withhold food and water 12 hours before your pet's admission appointment. For Exotics/Birds please call the hospital for withholding food and water instructions.
Name
Name
First Name
Last Name
Address
Address
City
State/Province
Zip/Postal
Are you or any family member experiencing any signs of COVID-19 illness like fever, cough, body-aches, or loss of taste or smell?
Have you been exposed to anyone knowingly with COVID-19 illness in the last 14 days?

Note:
Masks are now optional to wear on the day of your appointment.

I, the undersigned owner, or owner's authorized agent of the above pet certify that
Is your pet on medication?
I have been informed that my pet is in need of preventive or therapeutic dental care and hereby consent to the appropriate procedures described to me by the veterinarian and her staff at this facility. These procedures include but are not limited to the following: 1) dental prophylaxis (routine teeth cleaning and polishing), 2) extractions, 3) oral surgery to close gaps left by extractions, 4) root planings, 5) dental x-rays, and 6) antibiotic gel implants.
I am aware that dental procedures for animals require the use of anesthesia to: 1) maximize visualization of the gums, teeth, and oral cavity, 2) minimize movement and discomfort, and 3) provide for the safety of the pet, doctor, and hospital staff. I understand that some risks always exist with anesthesia and dental procedures and that I am encouraged to discuss any concerns I have about those risks with the veterinarian before these procedures are initiated.