Dental Treatment Consent - Eastern Shore Animal Hospital & Urgent Care

Owner's Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Pet's Name*

Species*

Breed*

Sex*

M
F

Color*

Weight*

Patient Procedure: Dental Cleaning with or without extractions/oral surgery

- I, as the owner or authorized agent of owner, grant my consent for Eastern Shore Animal Hospital to receive, prescribe for, treat and/or operate upon the above names pet. It is understood that there is inherent risk associated with medical and surgical treatments. Specific results can never be guaranteed in dealing with the complexities of living animals.
- I understand that unforeseen complications can result even though professional, approved, methods will be used by the team at Eastern Shore Animal Hospital.
- I understand that flea treatment is required if live fleas are found on my pet.
- I accept all financial responsibilities for my pet and understand that payment for services rendered is due at the time of discharge.

Please read carefully and choose one of the following pertaining to emergency life saving procedures:*

Should an emergency arise I give permission to ESAH doctors and staff perform any necessary live saving measures on my pet.
I do NOT give my consent to have ESAH doctors and staff perform life measures on my pet in the event of an emergency, otherwise stated as a DNR (do not resuscitate).

If dental extraction or oral surgery is needed: Please choose one of the following options.*

I authorize all doctor recommended procedures/ extractions no matter the cost.
I authorize doctor recommended procedures/ extractions but not exceeding a certain amount (specify below).
I decline all additional doctor recommended procedures without contacting me for further authorization. I understand that if the staff of Eastern Shore Animal Hospital is unable to reach me, no additional procedures will be performed.

Do not exceed this amount if dental extraction or oral surgery is needed.

Additional services requested for my pet while at Eastern Shore Animal Hospital:

Call for prices.

Microchip Implant
Nail Trim (complimentary)
Pre-Surgical Bloodwork
Other

Other additional services requested:

I have read and fully understand the terms and conditions set forth above.

Electronic Signature

Date*
MM slash DD slash YYYY

Date

Telephone number where I can be reached today*
Telephone number where I can be reached today

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Dental Treatment Consent Form