Dental Release Form

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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.

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.


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