Dental Release Form

Owner Name *

First

Last

Date *

Pet's Name *

I hereby authorize Union Pet Hospital and its designated associates, technicians or assistants to treat, anesthetize, prescribe medications for, and perform specified diagnostic tests or surgery on my pet who is named above. I understand the risks associated with these procedure(s) and know that all reasonable precautions will be taken against injury, escape, or destruction of my animal and will not hold Union Pet Hospital responsible in event of such. *

I have read and agree.

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

Yes
No

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 diseases. 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 select the appropriate response below. *

Yes - I authorize these additional procedures and 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 any additional procedures. In the event that I can not be reached, I do not authorize additional procedures.

Additional Options (Select all that you'd like)

Microchip, registration & enrollment ($100)
PlaqueOff Dental Powder 60 gm bottle ($24.34)
PlaqueOff Dental Powder 180 gm bottle ($49.50)

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, we will treat at a cost of $12.30.

I fully understand the terms of this agreement and do authorize the hospital staff to perform the above indicated services on my pet. It is also agreed that payment in full is due upon release of my pet and if I do not pay this account as agreed that past due accounts are subject to costs of collection. I am the owner or authorized agent of the owner of the pet presented for care. *

I have read and agree.

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

Phone Call
Text Message
Email

Phone number where you can be reached today *

Alternate phone number

Email *

Digital Signature *

Clear Signature

We provide exceptional pet care in Union, KY!

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