Decatur Dental Release Form

Client Name: *

Pet Name: *

Contact Phone Number: *

Secondary Phone Number:

Name of person responsible for making medical decisions: *

Responsible party's phone number (if different):

Your pet is being dropped off for a dental cleaning procedure today, which includes scaling, polishing and fluoride treatment of the teeth. For the safety of your pet and as required with all other anesthetic procedures, a blood profile will be performed prior to the procedure. Please note, however, that there are still potential risks involved with anesthesia. The cost of this blood work is included in the cost of the dental procedure. There are, however, other potential costs that may be incurred today, such as possible tooth extractions, dental x-rays, and/or medications (i.e. antibiotics, pain meds, etc).

The prices for tooth extractions, dental x-rays and medications are listed below, as well as other potential additional costs:

The cost of dental x-rays is between $45 - $188, depending on species and the number or extent of the x-rays. The price of antibiotics and/or pain medication will be between $35-$85, depending on the weight and the medication used. To ensure a flea-free environment, it is our policy to administer flea medication (capstar)if fleas are noted on your pet, at a cost of $10.00-$13.00.

During your pet’s dental procedure, if the veterinarian determines your pet may need one or more teeth extracted, and/or dental x-rays, it may not be feasible to contact you for your authorization beforehand, since your pet will be under anesthesia.  Please review each of the three options below, to let us know how you wish this matter to be handled if it becomes necessary.

Please choose and sign ONLY ONE of the three options listed below.

Please list other requested procedures

I request an estimate

I do not need an estimate at this time.