Form Builder

filter comments

Owner's Name

Address

City

State

Zip

Primary Phone

Secondary Phone

Email

notes2

Pet Information

Pet's Name

Species

Breed

Sex

Date of Birth/Age

If not already, would you like your pet microchipped today? ($42)

notes1

A Dental Prophy Includes:

A complete scaling of the teeth, polishing, flouride treatment, periodontal charting and an oral examination by the doctor.

The doctor will provide you with an estimate prior to the procedure.

Owner Consent and Release

Consent to perform extractions and necessary procedures

Many pets require anesthesia before a doctor can complete a thorough dental exam. Each tooth must be carefully evaluated so the veterinarian can choose the best treatment. We recommend completing all meeded dental procedures during this visitso you can avoid scheduling another appointment with additional sedation costs.

Please check ONLY ONE of the options below:

Perform any necessary extractions at this time. I understand my pet will be started on antibiotics and pain medication. I agree to assume financial responsibility for these charges.
Call me at the number below after the dental exam to provide an estimate of any additional procedures. I understand if I cannot be contacted at this number, necessary extractions will be performed and my pet will be started on antibiotics and pain medication. I agree to assume financial responsibility for these additional charges.
Call me at the number below after the dental exam and provide an estimate of any additional procedures. Do not proceed without authorization. I understand that if I cannot be contacted no extractions will be performed and I assume all responsibility for any complications this decision may cause for my pet. I also understand that if I decide to have these additional services done later, I have to schedule for a different appointment with separate charges.

Would you like any expired vaccines or tests updated?

Yes, all annual vaccines and tests
No
Yes, but only the following:

Additional treatments to be performed:

Please be aware that each additional treatment will be performed at additional costs that may or may not be included in your previous estimate.

notes3

Release for Medical Treatment

I, the undersigned, do hereby certify that I am the owner, or duly authorized agent for the owner, of the animal described above and that I do hereby give Georgetown Veterinary Hospital, its veterinarians, agents and/or representatives full and complete authority to perform the dental procedure prescribed above. I also grant permission to perform any other procedure that, at her discretion, may be useful to promote health of the above described pet, and I do hereby and by the presents forever release the said doctor, her agents or representatives from any liability arising from said dental/surgical procedure on said animal. I accept full financial responsibility for all tests and treatments that I verbally authorize during my conversation with the doctor. I understand that payment is due in full when my pet is discharged.

I understand that if evidence of fleas is found on my pet during the examination, a dose of CAPSTAR will be administered at my expense. (Approximately $8)

I agree to the terms stated above.

I agree.

Today's Date