Dental Procedures Release Form

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Basic dental cleaning/polishing includes the following services:

Full Mouth Dental Radiographs: $80.00
Pre-medicating and Anesthesia: $57.15
Dental Cleaning/Polishing: $232.29
Total: $369.44

Signs of periodontal disease in dogs and cats include bad breath, loose or discolored teeth, mobile teeth, drooling, dropping food, and bleeding from the mouth. Periodontal disease can be painful for your pet and compromise their health.

Occasionally, while performing a professional cleaning, we will find it necessary to perform additional services. These services include radiographs, tooth extractions, and medication administration and incur an additional cost. Unless the box below is checked, we will make an effort to contact you if we feel these are necessary. If you are unreachable, Double Oak Mountain Animal Hospital will perform medical treatment as considered therapeutically and/or diagnostically necessary.

Doctor is authorized to proceed with services based on his/her recommendation. I do not need to be called prior to treatment.(Required)

I, the undersigned, certify that I am the owner, or authorized agent for the owner, of the above described animal. I authorize the doctor on duty and assistants to perform the procedures listed above, including the administration of pain relief medications, sedatives, and/or anesthetics, as well as any necessary and appropriate medical, radiology, surgical nursing, diagnostic, and/or emergency care for the animal. I have been advised as to the nature of the procedure and the potential risks and understand that no guarantee of successful treatment can be made. I have been informed and am clear in my understanding of the fees associated with services to be performed. I have read and understand the reasons for and the risks of the above and attached authorized procedure(s), and assume full responsibility for all charges and services incurred to the described animal. I understand that in the event of anesthetic complications or if emergency medications must be administered, additional charges could be incurred.

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This field is for validation purposes and should be left unchanged.