Dental Release Form

Save time during your next appointment! Complete your required forms online from any device at any time before your visit.

Get Started

Dental Release Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Client ID:

Client Name: *

Phone *

Address

Address Line 1

City

State

Zip Code

Patient Name *

Sex *

Species *

Arrival Date:

Ok to do ALL procedures today recommended by the doctor
Please Contact me at the number provided prior to anything other than a cleaning if we cannot contact you to authorize any further treatments only a cleaning will be provided today

I would like the following procedures performed on my pet today (additional fees will apply):

Checkboxes

Pre-anesthetic blood panel
Clip Nails
Clean Ears

All pets left must be free of fleas and ticks, or they will be treated at the owner's expense. I, the undersigned owner of, agent of the owner of, or Good Samaritan responsible for seeking veterinary care for the pet identified above, certify that I am eighteen years of age or over. I consent to the surgical procedure of this pet by staff veterinarians at the Animal Care Center. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is initiated. Should unexpected life-saving emergency care be required and the attending veterinarian is unable to reach me, the hospital staff has my permission to provide such treatment, and I agree to pay for such care.

I understand that an estimate of the fees for the surgery listed above will be provided to me upon request and that I am encouraged to discuss all fees related to the surgery before the surgery is performed. I agree to assume full financial responsibility for the procedures and will provide payment via cash, credit card, or check at the time my pet is discharged from the hospital. In the event Animal Care Center finds it necessary to refer my/our account to an attorney or debt collector for collection of any outstanding balance, I/We shall be responsible for the attorneys or debt collectors fees and expenses as well as court costs and filing fees.

THIS CLINIC DOES NOT HAVE 24 HOUR SUPERVISION.

I have read and understand the presurgical information packet, which includes the
preanesthetic bloodwork, surgical information and estimate.

Available all day today at the following number *

Secondary Person/Number to contact *

Signature of Pet Owner or Person Responsible *

Clear Signature

Today's Date *

Dental Release Form

Dental Release Form

THIS CLINIC DOES NOT HAVE 24 HOUR SUPERVISION.

We’re excited to meet you

Have a question?

Address

How to Reach Us

Our Hours

We proudly serve the pets of Joppa, MD and beyond